Ethic in Nursing

Medicolegal Library 4
Edited by A. Carmi
Nursing Law
and Ethics
Edited by A. Carmi and S. Schneider
With Contributions by
M. B. Agostino K. Asplund B. Bandman E. L. Bandman
R. Bergman K. M. Boyd A. V. Campbell A. Carmi
R. Crow A. J. Davis M. deChesnay E. Dixon R. Eldar
M. J. Flaherty S. T. Fry C. P. Germain L. C. Greif
I. H. Haugen L. Hockey S. Kottek M. Levine
U. Lowental M. S. Macmillan D. Michaeli A. Norberg
K.M.J.Rea S.M. Roach S.S.Rosario J.Rosenkoetter
M. Rosenkoetter J. Sansoni R. A. Schrock K. Scherer
C. Searle V. B. Shachar Y. A. Shapira S. A. Smoyak
C. Sus H. O. Thompson J. B. Thompson L. R. Uys
N.Wagner
Springer-Verlag
Berlin Heidelberg New York Tokyo
Judge Amnon Carmi
P.O.B. 6451, Haifa 31063, Israel
Prof. Dr. Stanley Schneider

Summit Institute
Wurzweiler School of Social Work, Yeshiva University
Michlala Jerusalem, Women's College
P.O. B. 7446, Jerusalem, Israel
ISBN-13: 978-3-540-15253-8 e-ISBN-13: 978-3-642-82468-5

DOl: 10.1007/978-3-642-82468-5
Library of Congress Cataloging in Publication Data

Nursing law and ethics. (Medicolegal library ; # 4) 1. Nursing ethics. 2. Nursing-
-Law and legislation. I. Carmi, Amnon. II.Schneider, S. (Stanley) III.Agostino,
M. B. IV. Series. [DNLM: 1. Ethics, Nursing. 2. Nursing--legislation. W1
ME768TR no.4 / WY 33.1 N974] RT85.N881985 174'.285-2830
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Contents
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
Nursing: State, Status and Statutes

A.Carmi " ............ . 3
II. Nursing: Legal Aspects . 11
Introduction . . . . . . . . 13
Rights and Responsibilities . 14
Human Rights in the Nurse-Patient Relationship
B. Bandman . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Whats Wrong About Rights
M.Levine . . . . . . . . . . . . . . . . . . . . . . 22
Medical Care: The Problem of Autonomy
U. Lowental. . . . . . . . . . . . . . . . . . 28
Rights and Responsibilities of Nurses as the Basis for Their
Contracts with Society, with Patients, and with Colleagues
M. J. Flaherty . 30
Treatment. . . . . . . . . . . . . . . . . . . . . . . 39
Legal Implications of Standards of Nursing Care
K. Scherer. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 39
Practice and Malpractice
K.M.J.Rea . . . . . . . . . . . . . . . . . . . . . . 45
Legal Aspects of Surgery in England
E.Dixon ............... . . . . . . . . . 54
Legal and Moral Rights for Mentally III People:
A Critical Argument
R.A.Schr6ck . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56
Involuntary Sterilization of the Mentally Retarded: Curtailing
Procreation Rights of Persons with Diminished Capability
to Claim Rights
S. T.Fry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61
VI Contents
Informed Consent
A.I.Davis . . . . . . . . . . . . . . . . . 67
Issues of Confidentiality in Health Care
L. C. Greif . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Father-Daughter Incest: Who Owns the Child?
M. deChesnay . . . . . . . . . . . . . . . . . . . 75
Prosecutors or Defenders: With Whom Should Clinicians
Align?
S.A.Smoyak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
III. Nursing: Ethical Aspects 89
Introduction .. 91
Moral Dilemmas 93
Moral Dilemmas in Nursing
A. V. Campbell . . . . . . . . 93
Law or Ethics: Which of Them Should Regulate Nursing
Practice?
I. H. Haugen . 98
Education . . . 103
Should Nurses Study Ethics?
I. B. Thompson and H. O. Thompson 103
The Work Environment as a Factor in Continous Ethical
Training
C.Sits .. .109
Research 115
Aspects of Ethics in Nursing Research
R.Bergman . . . . . . . . . . . . 115
The Ethics in Nursing Research
L.Hockey . . . . . . . . . . . . . .122
Implication of Ethics and Nursing Research for Patient
Advocacy
E. L. Bandman . . . . . . . . . . . . . . . . . . . . . . . . 126
Ethics and Research into Nursing Practice
R.Crow . . . . . . . . . . . . . . . . . . . . .132
Ethical Considerations for the Nurse Ethnographer Doing
Field Research in Clinical Settings
C. P. Germain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Contents VII
Attitude of Nurses to Euthanasia of Terminally III Patients

V. B. Shachar . . . . . . . . . . . . . . . . . . . . . . . . .. . 144
Decision Making . 151

A Framework for Resolving Ethical Dilemmas in Nursing
Education
J. Rosenkoetter and M. Rosenkoetter . . . . . . . . . . .. .. 151
Social and Role Constraints on Ethical Decision Making
by Nurses in Hospital
A.J.Davis. . . . . . . . . . . . . . . . . . . . . . . . . .. .. 160
A Simulation Game: A Tool for Teaching Ethical Decision
Making to Student Nurses in Israel
N. Wagner . . . . . . . . . . . . . . . . . . . . . . . . . .. . 165
Treatment. . 170
A Foundation for Nursing Ethics
S. M. Roach . . . . . . . . . . . .170
Ethical Imperatives in N~rsing
S. S. Rosario . . . . . . . . . . . . .178
Ethical Considerations in the Care of Dying Patients
L. Hockey. . . . . . . . . . . . . . . . . . . . . . . . . . 184
Ethical Problems in the Assessment of the Quality of Care
R. Eldar. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 188
Ethical Issues in the Care ofthe Elderly Under Socialised
Medicine
M.S.Macmillan . . . . . . . . . . . . . . . . . . . . . . .. .191
Feeding Problems
K. Asplund and A. Norberg. .197
IV. Nursing: Cultural and Religious Aspects .201
Introduction . . . . . . . . .203
The Economics of Caring
K.M.Boyd . . . . . . . . . .205
Culture .. .210
Illness. A Time of Stress Involving the Relationship Between
the Individual Personality and Cultural Background
M. B.Agostino and J. Sansoni . . . . . . . . . . . . . . . . . . . 210
VIII Contents
Religion . . . . .216
Nursing in Jewish Medical Ethics: Visiting the Sick
S.Kottek . . . . . . . . . . . . . . . . . . . . . . . . .216
Ministering to the Sick
Y.A.Shapira . . . . . . .220
The Implication of Radical Christian Philosophy
for Nursing Ethics
L. R. Uys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
v. Epilogue. . 231
Introduction . 233
The Dependent, Independent and Interdependent Functions
of the Nurse Practitioner: A Legal and Ethical Perspective
C. Searle . . . . . . . . . . . . . ~. . . . . . . . . . . . . . . . . 235
The Changing Role of Nurses and Its Implications
D. Michaeli . . . . . . . . . . . .' . . . . . . . . . . . .243
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

List of Contributors
M. B. Agostino
Via Pienza 201,1-00138 Rome, Italy
K.Asplund
Department of Advanced Nursing, S-901, 87 Umea, Sweden
B.Bandman
Long Island University, Brooklyn, NY, USA
E. L. Bandman
Hunter College of the City, University of New York
3341 Reservoir Oval, Bronx. NY 10467, USA
R.Bergman .
School of Nursing, University of Tel Aviv, IL-Tel Aviv 63474, Israel
K. M. Boyd
Society for the Study of Medical Ethics, 1 Doune Terrace
GB-Edinburgh EH3 6DY, Scotland, United Kingdom
A V. Campbell
Faculty of Divinity, University of Edingburgh, Scotland
United Kingdom
A Carmi
P.O.B 6451, IL-Haifa 31063, Israel
R.Crow
Nursing Practice Research Unit, Northwick Park Hospital
Watford Road, GB-Harrow, Middlesex, United Kingdom
AJ.Davis
School of Nursing, University of California, San Francisco
CA94143, USA
M.deChesnay
School of Nursing, Emory University, Atlanta, GA 30322, USA
E.Dixon
School of Nursing, Guy's Hospital, GB-London, SE 1, England
United Kingdom
R.Eldar
Faculty of Health Sciences, Ben Gurion University of the Negev
Beer Sheva, Israel
X List of Contributors
M. J. Flaherty
Department of National Health & Welfare, CON-Ottawa, Ontario
Canada
S.T.Fry
Kennedy Institute of Ethics, Georgetown University, Washington
DC 20036, USA
c. P. Germain
School of Nursing, University of Pennsylvania, 420 Service
Drive/S2, Philadelphia, PA 19104, USA
L. C. Greif
Department of Nursing, Tel Aviv University, IL-Tel Aviv 63474
Israel
LH.Haugen
Nursing Division, The Health Sciences of Norway, Oslo, Norway
L.Hockey
Nursing Research Unit, Department of Nursing Studies, University
of Edinburgh, GB-Edinburgh, Scotland, United Kingdom
S.Kottek
Department of the History of Medicine, Hebrew University
Hadassah Medical School, IL-Jerusalem 92-585, Israel
M.Levine
550 Sheridan Square, Evanston, IL 60202, USA
U.Lowental
School of Medicine, Hebrew University, IL-Jerusalem 92-585
Israel
M. S. Macmillan
Nursing Studies Research Unit, University of Edinburgh
GB-Edinburgh, Scotland, United Kingdom
D.Michaeli
Ministry of Health, Ben Tabai 2, IL-Jerusalem 92-585, Israel
A. Norberg
Department of Advanced Nursing, S-901, 87 Umea, Sweden
K. M.J. Rea
GB-Brentwood, Essex, United Kingdom
S.M.Roach
St.Francis Xavier University, Antigonish, CON-Nova Scotia
B2G 1CO, Canada
S. S. Rosario
Clinica Universidad de Navarra, E-Pamplona, Spain
List of Contributors XI
J. Rosenkoetter and M. Rosenkoetter

Columbus Country Mental Health Center, Whiteville, NC, USA
J.Sansoni
Via Pienza 201, 1-00138 Rome, Italy
R. A. Schrock
Dundee College of Technology, GB-Dundee, Scotland
United Kingdom
K.Scherer
647 Broadway, Winnipey, CON-Manitoba R3C OX2, Canada
C.Searle
University of South Mrica, POB 392, ZA-Pretoria 0001
South Mrica
V. B. Shachar
Ministry of Health, IL-Tel Aviv 63474, Israel
Y. A. Shapira
10 Abraham Shapira Street, IL-N atanya, Israel
S.A.Smoyak
4 Ronby Road, Edison, NY 08820, USA
C.Sus
Sub iron, Clinica Universitaria, E-Pamplona, Navarra, Spain
H. O. Thompson and J. B. Thompson

School of Nursing, University of Pennsylvania, Philadelphia
PA 91104, USA
L.R. Uys
University of Orange Free State, ZA-Bloemfontein 9301
South Mrica
N.Wagner
Tel Aviv University School of Nursing, Kaplan School of Nursing
IL-Tel Aviv 63474, Israel
I. Introduction
Nursing: State, Status and Statutes
A. Carmi
1 The Whole Truth
"Courts of Justice seem to think that anybody can speak the whole truth, and noth-
ing but the truth. (However), it requires many faculties to speak the whole truth, and
to say nothing but the truth."
This statement was not made by a learned judge, but written by Miss Florence
Nightingale, the lady with the lamp, in her "Notes on nursing - what it is and what
it is not", about 125 years ago.
The whole truth about nursing is not to be found in any court decision or statute
or in any declaration, nor is it to be determined solely by doctors or to be formed by
public opinion. Theirs might be the truth, but not the whole truth.
The qrucial issue, the most important question, will always be: what do nurses
think of themselves, and what will nurses do for themselves.
2 History
The whole truth about nursing is reflected by its comprehensive history. The devel-
opment of the nursing image has a long history.
Whereas criminal literature describes prostitution as the oldest female occupa-
tion, nursing records insist that nursing is the oldest of the professions of women,
with its roots to be found at the cradle of mankind. As there has always been dis-
ease, nursing started where man began to care for the sick.
The Old Testament describes various paranursing activities: Rebekah's nurse
accompanied her when she left with Abraham's servant to meet Isaac, and the pro-
phet Isaiah stated: "thy daughters shall be nursed at they side" (60:4).
Ancient Jewish law dealt with health and disease and took the first steps toward
prophylaxis.
Institutional nursing had been formally established by Christianity, particularly
through the Christian concept of charity with its origins in the Jewish tradition. The
Hebrews organized charitable societies for supporting the sick, while the Christians
built hospitals and maintained them. Some of their oldest hospitals were built in Is-
rael. Basil, the Bishop of Caesarea had already founded his hospital in 370 A. D,
with the institution named after him: the Basilias. Its staff consisted of physicians
and nurses. In the beginning of the 12th century, Brother Gerard had built a large
hospital in Jerusalem which was kept by the Order of the Knights of St. John. Other
hospitals were founded by the Crusaders in Jerusalem and Acre in those years.
4 A. Carmi
3 Sex in Nursing
During the course of history, various factors took part in the formation of the nurs-
ing image, with sex being one of the most important aspects in role differentiation.
With the experience of the past, bias and suppression should not be ignored by
those who strive for a substantial change. The secondary position of women in the
past and even in the present society has affected the legal, economic, and profes-
sional status of nurses. Nursing has always been influenced by social conceptions
inferring that women were less independent than men. Nursing was excluded from
the decision-making roles; these roles were kept in the hands of males. The subjec-
tion of nurses was coincident with the sUbjection of women. Considering the fact
that more than 90% of all nurses are women and that society under the general mas-
culine supremacy was not prepared to grant high status to women, nursing had to
struggle in order to be acknowledged as an important professional group.
Nurses should be aware of this phenomenon if they desire to put an end to the
discriminatory process. Nurses treat doctors (and females treat males) much the
same way as doctors see nurses as women with whom they work. The process of
change of attitudes must start within the nursing profession through self-education.
It is worthwhile indicating that many nursing schools still teach their students to ful-
fill submissive roles. They are trained to show strict obedience, which brings about
subordination and dependence.
Some psychologists claim that the nurses' urge to treat the sick originates from
the mothering instinct and that nursing is therefore part of feminine nature.
However, nursing should not be given an inferior status, even if it consists of
some female traits according to this (male-oriented) psychological theory. In con-
clusion, if the nursing profession strives to improve its position, nurses must be
aware of this problem and, accordingly, maintain their public campaign and the
education of their next generation.
4 Who Is More Important?
There is no way to measure or determine the importance of nursing. Every state-

ment depends on various questions, such as: "What is the purpose of the question"
or "Important to whom?" However, the importance of a profession is determined
inter alia by the reflection of its image and its status.
Any project purporting to raise the nurses' status cannot disregard their present
image. Different images of nurses are conceived and reported by various groups of
patients, physicians, and nurses. Preliminary research, which has been recently con-
ducted in Israel, presents the attitudes of five different communities with regard to
the importance of nursing. The research comprises the views of 120 physicians and
nurses, of 120 students of medical and nursing schools (3rd year), and of 390 pat-
ients from various hospitals.
One of the questions presented to the participants was: Who is more important:
doctors or nurses? Several persons, especially doctors, replied in an aggressive man-
ner: How could anyone present such a silly question? Others were more patient:
Everyone may be important in his own field or activity. The emotional reactions
were of most interest to us, but we turned to examine the other replies as well.
Nursing: State, Status and Statutes 5
For both the patients and their physicians, 70% were of the opinion that doctors
are more important than nurses. Only 5% of the doctors and 20% of the patients
stated that nurses are more important than doctors. The following replies were the
most interesting ones: Of the students in nursing school, 60% claimed that doctors
are more important. However, they can be expected to change their attitude shortly,
since only 30% of the registered nurses were of the same opinion.
Another part of the questionnaire dealt with the question: How are doctors be-
having toward nurses? Physicians (80%) and patients (81 %) were definitely satis-
fied. Nurses (63%) and nursing students (57%) were less content.
The next question was: Should anything be done so that physicians will treat
nurses in a better way? Both doctors and patients (62%) believe that there is no need
for any improvement. Nurses (82%) and nursing students (90%) emphasize the need
for a radical change.
It is interesting to indicate the different replies given by young people of approx-
imately the same age: Medical students hold (74%) that doctors treat nurses in a
proper manner and that there is no need for any improvement (60%). On the other
hand, nursing students are of the opinion (43%) that many doctors do not behave
properly toward nurses and that a big effort should be made in order to make things
better (90%).
This gap reflects the difference of opiQions and the lack of mutual understand-
ing which already exists among the young members of the medical and nursing pro-
fessions.
What about the behavior of nurses toward doctors? Patients seem to be content
(93%) and nurses feel the same (93%). Physicians are less happy (71%), and the re-
plies of the medical students (69%) perhaps express their well-known fear of the
older and more experienced nurses. Various replies were supplied to the next ques-
tion: Should anything be done in order to improve nurses behavior toward physi-
cians? Of the doctors, 86% claim that a real change should be made. This attitude
reflects the doctors' convinctions that it is the nurses' task to do their utmost in or-
der to raise the level of the doctor-nurse relationship. Nurses may disagree with
such a sweeping assumption, but they should not disregard it because the improve-
ment of that relation depends upon both parties.
It is worthwhile mentioning, however, that not less than 70% of both nurses and
nursing students admit that nurses should improve their behavior towards doctors.
Various factors are involved and applied in the campaign for better wages or
higher status, including the nature of the work and its burden or level of difficulty.
Diverse replies have been given by nurses and physicians with regard to the ques-
tion: Whose work is harder? Of course, there is no scientific way to measure this is-
sue, nor are there any objective criteria, which may supply the "correct" answer. The
only reason for this question was to evoke certain emotional reactions and examine
them.
Thus, physicians state (62%) that their work is harder, while nurses claim (73%)
that their work is harder.
Of the doctors, 31 % admit that nurses work harder than they, but only 7% of the
nurses agree that physicians work harder than they. Concerning the younger gener-
ation, we found that 88% of the nursing students believe that nurses work harder,
while less than half of the medical students (32%) hold the same view. Th~se replies
6 A. Carmi
show the power of education, or if you wish, "brain-washing," which is applied at

different schools. Last, but not least, patients believe that nurses (68%) work harder
than doctors (22%).
And, finally, most of the patients prefer female nursing treatment to male treat-
ment (62%; doctors even 78% !), but the patients prefer male medical treatment
(57%) to female treatment (28%).
What should be done in order to improve the relations between nurses and doc-
tors?
Most of the participants indicated the need for forming better mutual relations
within the clinics and also outside the working frame, such as social meetings, part-
ies, etc. We have collected various suggestions, including the exchange of informa-
tion of working procedures, attending seminars and advanced studies, taking part
in clinical discussions, and planning treatment together, Maybe the most important
suggestion was to teach doctors and nurses how to function properly in an interdis-
ciplinary staff. No less important was the claim for mutual understanding and re-
spect.
However, one cannot disregard the pessimistic views of various desperate parti-
cipants. Some physicians content themselves only with the increase of the nursing
level.
Several physicians compla4ted about their low earnings, and one doctor stated
that nothing will be changed unless nurses change their character. A young medical
student proposed to fire every nurse who has reached the age of 30, and his sex-
minded colleague explained that doctors start their relations with nurses near the
bed (of the patient) and end it on the bed.
Nurses, on the other hand, admitted that they should primarily acknowledge
their own value. They demanded that physicians should accept the fact that nurses
are human beings. One nurse suggested that doctors take part in the process of mak-
ing tea or coffee in the clinics. Another young and frustrated student exlaimed that
no improvement should be expected until the doctors would at least conceive that
nurses are not just fool creatures.
5 What to Improve?
The self image of the nurse appears to be at fault, as Hinsvark cynically stated:
"Where the doctor walks in, the nurse walks out."
Physicians could never have attained their domination of nurses if the nurses
had not allowed it. Apparently, many nurses are still afraid to take risks, to make de-
cisions, and to treat patients even when they are entitled and capable to doing so. In
the process of modification, the change of image should start at home. Nurses must
assume their responsibilities in order to form a different image of themselves and
for themselves. Only then should their true image be presented and promoted to the
physicians and to the public at large.
Social status is not given, but gradually assumed or attained. Nurses will feel an
increase in their status while assuming a larger role within the community of the
health professionals.
Very soon we shall confront a growing demand for nursing care. Such a demand
will derive from various social and economic sources: the growth in population, the
growing interest in one's state of health, new patterns in the delivery of health care,
and even rising medical costs.
Nursing should grow and exhance itself through self-education and self-train-
ing. This can be expanded into the challenges for a higher status, and looking for-
ward to emerging as a dominant factor in the field of health maintenance.
It is commonly accepted that the essence of a profession is that it is an organiza-
tion of an occupational group based on the application of special fields of knowl-
edge, with its own rules and standards for the protection of the public and profes-
sionales.
What is urgently needed for the IlJ,lrsing profession is a new definition of both
the framework and its' contents. The range of functions should be expanded and
the scope of nursing should be broadened in order to meet various demands. The
profession has changed throughout history, paralleling the needs of society. Public
awareness of scientific advances during the last century has created demands for
better services. Health and high levels of standards of health have been acknowl-
edge as fundamental rights of every person. The changing role of nursing should
therefore be perceived in the same tenw;. Health care is provided by many health
disciplines and is not just limited to the treatment of illness or disability. It com-
prises therapeutic care, health maintenap.ce, preventive treatment, restorative mea-
sures, and health education.
In order to be recognized as a dominant factor in the field of health care, nurses
have to build and define their unique role.
Physicians control the decision-making process with regard to the care of the
patient. They stand at the top of the pyramid of the health professions, keep the
monopoly, and dominate the field. Medicine may put obstacles in the path of nurs-
ing's efforts to expand its role and to become an independent profession of higher
recognized status. Physicians are not prepared to regard nursing as significant as
medicine. Also, economically they prefer to keep the control over the health care
system in their hands. In the past nurses had only fulfIlled the directions of the doc-
tors, who had applied absolute authority and control of both the treatment and the
nursing of the patients. Any expansion of the nursing activities may infringe on
those activities, which had previously been carried out by the medical profession. It
is the overlapping areas that cause the trouble.
Nurses will find it difficult to challenge the dominant role of the doctors in the
fields of diagnosing illness and curing disease. They should try, therefore, to func-
tion autonomously in other areas of health care while continuing to carry out the
physicians' instructions.
Figuratively speaking one may draw two circles. The smaller circle represents
medicine, which deals mainly with illness, and the larger circle represents health
care, as provided by all health disciplines. Nursing, emerging from its secondary
role in the small circle and entering the wider field as described in the second circle,
may find there its real identity and fulfill there its full role.
This type of nursing may deal with the personal and social needs of the patient
and his family, the preparation of health care programs, health counseling and
health teaching, as well as health research. In particular, nurses will have the imme-
diate contact with people entering the health care system, deal with the care of
8 A.Carmi
healthy children or older people, undertake the care of healthy women throughout
their pregnancy, treat patients with commonly occurring health problems, and ad-
vise people on health matters.
It is unlikely that either the physicians, whose traditional role is challenged, or
members of other health disciplines will be prepared to willingly accept this nursing
concept. However, the ever-growing shortage of physicians, especially in general
practice and in general pediatrics, and the unavoidable medical concentration on
sick care activity might help nurses in their campaign.
Nursing now has a real opportunity to become a dominant factor, forming the
kind of health care system which will meet the needs of the public and extend care
to larger numbers of patients.
6 How to Improve
The status of nursing will be improved if nurses try to effectuate change in the fol-
lowing five areas:
1 Selection of students. Modem procedures, which will guarantee the admission of
the best-qualified students to the nursing schools must be applied.
Miss Nightingale criticized what she called a commonly conceived idea: that it
requires nothing but a disappointment in love or the want of an object to tum a
woman into a nurse. She cynically indicated the case of a stupid old man who was
set to be a schoolmaster because he was "past keeping the pigs."
Judges in courts of justice are taught that they should not limit their compassion
to the defendant only. They should show mercy to his victim too. Similarly, while
checking the qualifications of the applicants to nursing schools, the examining
boards should show some mercy to the potential patients too. Attainment of high
standards from the beginning will ensure the success of the whole journey.
2 Education will always be the most important factor. Advanced systems of nursing
education and training must be persistently looked for and formed, in order to raise
the professional level.
Nurses should consistently update their knowledge, and continuing education
must be required for relicensure.
3 Better treatment. Florence Nightingale stood for the principle: "Nurse the sick,
not the sickness." The two following illustrations reflect her idea more than volumes
of sophisticated theories: Never allow a patient to be woken, and always sit within
the patients view so that he must not tum his head around to look at you. In other
words, do not look upon patients as made for nurses, but upon nurses as made for
patients. Regard your patient as the most important person in the hospital.
Patients will be the key persons in the determination of the status of nursing in
the future. The communities of sick people will take part in the formation of socie-
ty's attitude toward nursing. Therefore, better treatment for the sick will also im-
prove the image and the status of nursing.
4 Better relations with doctors. The status of nursing will be partly formed or influ-
enced by doctor's attitudes. The relationship between nurses and physicians will al-
ways remain a most important factor in the health care system. The attitudes of both
doctors and nurses might be modified through the process of education. This kind
of education should be the mission of the leading authorities in the schools of medi-
cine and nursing.
5 Increasing authority and responsibility. Nurses are legally obliged to use reason-
able care, which will be determined according to the common practice. Misapplica-
tion of any activity which is within the scope of the nurse's responsibility, or failure
to carry out such a duty, might be regarded as negligence. On the other hand, nurses
should not undertake to perform anything which is beyond their qualifications or to
function in an unauthorized extended role.
Licensure laws are enacted in order to protect the public's health and safety.
Their purpose is to ensure that nurses are able to apply reasonable standards of
practice. The expansion of the scope will carry heavier responsibilities on the part
of the nurse. It is a must that nurses be trained and prepared to bear the burden of
such a responsibility.
New laws can be expected to grant autonomy and authority to nurses. Never-
theless, one should not regard legislation as the primary solution. Until now the on-
ly purpo'se of nursing licensure acts Wl;lS to protect the public from incompetent
nurses. Much preparation is required for the enactment of new laws which will pro-
tect nurses and provide them with the right to practice as independent practitioners.
Legislatures have little or no knowledge of nursing dilemmas. They should be edu-
cated and public opinion should be formed.
The application of such laws will meet many difficulties. Substantial funding
will be required for the education of all nurses. Comprehensive health treatment by
nurses will also be a cause for difficulties. Various groups of physicians and health
practitioners, as well as injured patients, may legally challenge the nursing profes-
sion. Governments and courts emphasize consumer rights and tend to compensate
injured persons for all types of damages. Unreasonable expectations of patients
with regard to the capabilities of nurses may bring about frustration and aggressive
reactions. Nurses should understand and accept that rights carry duties and that in-
dependence means responsibility.
7 Conclusion
Nursing is on the verge of crucial changes. It has to face many difficulties. Dream-
ing and hoping fUr a better future will not suffice. Even "the coolness of the soldier
and the tenderness of the mother" will not do. New approachs are required for
meeting nursing's needs. Nurses should strive to attain self-awareness and self-edu-
cation. And, last but not least, they should initiate not only a new kind of relation-
ship with the medial profession but a close cooperation with jurists who know nurs-
ing laws, who are aware of nursing dilemmas, and who are ready and able to devote
their skill and show their goodwill for the advancement of nursing.
II. Nursing: Legal Aspects
Introduction
The papers in this section on the legal aspects of nursing can be divided into two
parts: (a) the rights and responsibilities of nurses, patients, and the medical system
and (b) treatment, with its legal ramifications.
How does one decide whether patients' rights or the health professional's rights
are to be considered more seriously? Is there an absolute "right" or "wrong"? Since
legal rights are sanctioned by constantly changing social and political climates, this
may, in effect, diminish the possibility of anything absolute.
The question of the "equivalency" of legal and moral rights is also addressed.
Due to the prevalent vagueness with regard to bioethical issues as they affect hu-
man and legal rights, often we become absorbed in philosophical polemics without
being able to arrive at anyone answer. In order to move beyond the ethical/theoret-
ical fonnulations, there is daily confrontation in the nursing profession - the practi-
cal application of theoretics.
The nurse, as a professional, wants,'to be viewed with professional status. This
necessitates a contractual agreement with patients, colleagues, and society as a
whole. This job status allows decisions to be made with professional weight behind
them. It also involves greater responsibility on the part of the nurse. Thus, violation
of patient self-determination in order to protect his best interests may be a type of
decision that the professional nurse may have to make. In addition, the counter-
transference feelings of the nurse have to be taken into account, for individual bi-
ases may affect how the nurse deals with patients.
Confidentiality is a value that is both ethically and professionally governed.
However, should professional secrecy "protect" the patient by keeping certain in-
fonnation unavailable to him? What are the rights of patients - especially the men-
tally ill? Are these rights ethically/morally and/or legally governed?
When addressing such philosophical issues, the question of practice/malprac-
tice arises. The treatment professionals and legalists can pursue whether there is a
universal level of care or universal level of negligence - or must one weigh the indi-
vidual merits of each case. Is there a universal consensus on standards of care? If so,
is this consensus legally or morally based.
In searching for the fine line between the legal and moral position, complica-
tions and overlap are found in the more difficult-to-treat issues: i. e., the mentally re-
tarded, the emotionally disturbed, cases of incest. "Who is the client" is very often
the question that must be posed in order to arrive at basic principles.
This section includes papers from Canada, England, Israel, Scotland, and the
United States. They offer an international flavor to the legal aspects of nursing, with
the overlap between rights and responsibilities and treatment an inevitable reality.
Rights and Responsibilities
Human Rights in the Nurse-Patient Relationship

B.Bandman
1 Introduction
Nearly everywhere wo look, we find a growing number of assertions of rights in pat-

ients' and health professional relationships. These assertions of patients' and health
professionals' rights present a basic issue: To what extent do patients and health
professionals have rights? This issue may be illustrated by citing some examples:
(a) Mary, a good nurse, claims the right to refuse to assist in performing abortions
[1,2]. (b) But then there is Florence, a 17-year-old, sexually active, single, impover-
ished parent. She claims a right to terminate her pregnancy with first trimester abor-
tion, so she can care for her other three children. 1 The only available nurse is Mary.
(c) Then there is Mary's friend, Tena, a nursing instructor, who believes that she has
a right to recommend Laetrile to her cancer patient in place of conventional medi-
cine.
The rights of nurses are not the only ones that generate dilemmas. (d) There is
the case of Ben, a 2-day-old infant with trisomy 18. He has a right to be saved, ac-
cording to his parents, even though 87% of infants with trisomy 18 die in the first
year, and two other infants urgently need the only available respirator [4). Perhaps
even more controversial is (e) the case of 13-year-old Phillip, a mild child with
Downs syndrome. His friends say he has a right to life-saving surgery despite his
parents' refusal to consent. 2 (f) At the other end of the age spectrum is Ivan who is
82 and has a normal IQ. Nora, a nurse, says Ivan has a right to a prostatectomy de-
spite his nephew's refusal to consent [6]. Does age or IQ make a difference between
Phillip's and Ivan's right to live? Then there is the case of (g) Edward, a high-anxi-
ety cardiac patient who has had several near-fatal heart attacks. He claims the right
to refuse tranquilizers. Edward is, however, unknowingly given tranquilizers for
life-saving reasons, thus setting aside his right to know the truth about what is being
done to his body [7, p 135]. Or consider the case of Jane. (h) She requires a cranioto-
my. Jane's family members assert that she has a right to have her wishes honored
and not be resuscitated in the event of respiratory failure. Her wishes are to donate
her kidneys as a "gift of life" to a suitable recipient [8]. The question arises: If Nora
or Mary is Jane's nurse, is she obligated to save Jane's life or facilitate her right to
die? Does a patient's wish to die imply a right to die? Lastly consider (i) the case of
Herbert, a depressed, suicidal man who believes he has a right to jump out of the
22nd-story hospital room; and if he has a right to die, then Mary, the nurse, has no
right to restrain Herbert [7, P 136].
1 The format of these examples is adapted from Engelhardt [3)

2 Adapted from George F. Will [5)
Human Rights in the Nurse-Patient Relationship 15
In response to these cases, there are four positions to be taken:

1. Patients and health professionals have no rights.
2. Patients and health professionals have option rights but no subsistence rights.
3. Patients and health professionals have limited option and subsistence rights, but
in a pinch subsistence rights override option rights.
4. Patients and health professionals have unlimited option and subsistence rights.
I will try to show that the third position is more defensible than the others and that
this position provides a basis for deciding whose rights in these cases are worth tak-
ing seriously. Several philosophical moves have recently been developed in defense
of patients' and health professionals' rights.
2 Philosophical Moves
2.1 Quorum Feature
One philosophical move consists in applying the idea of "quorum features" to the
question, "When does human life begin and end?" [9]. You know what a quorum at
a meeting is. Usually a previously agreed minimal number of persons have to be
present for there to be a meeting. So, one philosophical move consists in applying
the idea of a quorum feature to the question, "When does human life begin and
end?" A person who lacks the quorum or majority of essential features of an ordi-
nary person, such as one who has multiple deformities or lacks consciousness or has
trisomy 18, gives a reason to doubt the viability of such a person's life.
2.2 Tracing and Examining for Appropriate Metaphors and Models
A second, four-part move consists, first, in considering a viewpoint which purports

to provide an answer to a question such as, "When does human life begin and
end?" or "What is a person?" This move consists, second, in tracing that viewpoint
to some deeply acknowledged metaphor or metaphors on which defense of its view-
point depends philosophically. Third, one examines the metaphor to determine
how it applies or breaks down in practical discourse. One may consider, fourth,
whether supplementary or alternative metaphorical analogies aid in the defense of a
given viewpoint.
In regard to a pregnant woman, for example, one may ask the metaphysical
question, "Is she one being or two?" [10] To individuate at the moment of concep-
tion is to regard a woman and her fetus as two basically equal beings. This view gen-
erally regards a woman as a passive receptacle in whom life is implanted. Alterna-
tively, a woman may be seen as a receptacle into which an item is inserted for the
completion of a productive or creative process. On this essentially passive view, a
woman does not create "the gift oflife" within her, to cite St. Thomas Aquinas's in-
sightful metaphor [11], but rather receives life. An opposing perspective, however,
views a pregnant woman as a property or factory owner, one who may do with her
own body, as with her property, as she pleases. On this view, a woman owns her
16 B.Bandman
body, which implies that she may do with it as she wishes. Each metaphor may be
examined for its illumination as well as for its implied difficulties. Life, for example,
is not always a gift, as the examples of the infant with trisomy 18 or the patient in
need of a craniotomy amply show. On the other hand, human life is not quite like
someone's property or factory, contrary to the claim of some writers that a mother
makes a baby.
2.3 BiologicaUBiographicallSociallCognitive Distinction
A third move by J. Rachels and W. Ruddick distinguishes biological or zoological

life from a biographical life. A person who has hopes, projects, a past, joys, frustra-
tions, a future with expectations and prospects - all of which presuppose conscious-
ness - is said to have a life [10]. If you can make an omelet or tie a shoestring or plan
a vacation or build a castle in the sand or drive a car or playa musical instrument or
have a project, you're living a biographical life, not just a biological life, which Ka-
ren Ann Quinlan is leading.
Missing in the biological!biographical distinction is that one also has a shared
social life with others. All sorts of evil or indifferent individuals have solitary pro-
jects that don't contribute to a socially worthwhile life. A socially worthwhile life al-
so calls for appropriate recognition of, and training in, standards and skills of sus-
tained intellectual judgment, a common understanding of the methods and results
of cognitive disciplines, as well as appropriate regard for, and familiarity with, rules
of evidential backing. The biological! social! cognitive distinctions rule against
identifying someone as a person who has extreme physical or intellectual or social
or psychological handicaps, such as trisomy 18, on the grounds that he is unlikely to
have a humanly worthwhile life. These distinctions also support a woman's right to
terminate an unwanted pregnancy on the ground that a woman in this predicament
is unlikely to provide a worthwhile human life for yet another child. By implication,
the biographical!social!cognitive distinction rationally counts against a nurse's
right to refuse to assist in such abortions. Lastly, the cognitive requirement gives a
reason against a nurse recommending Laetrile.
2.4.5 Examining the Meaning and Importance of Rights
A fourth philosophical move in defense of patients' and health professionals' lim-

ited rights consists in clarifying the meaning and importance of a key concept, such
as the concept of rights. Rights have variously been defined as permissions, claims,
powers, and entitlements. Each definition has defenders and opponents. Rights
seem to be many faceted and too complicated to expect satisfactory one- or two-
word definitions. We might instead look to some common features generally recog-
nized as conditions of any right.
One condition of any right is freedom. To have a right based on freedom is to be
accorded a sphere of autonomy or self-determination, to exercise one's rights as one
chooses, and to be immune to the charge of wrongdoing. It is the area of one's life
which, as Joel Feinberg aptly puts it, one is the "boss" [12]. Two writers refer to a
right as a "fenced in" backyard where one may do as one wishes [13J. The right to be
free, for patients and health professionals alike, includes the right to be treated ra-
tionally, which implies the right not to be coerced, brainwashed, lied to, deceived,
unknowingly given drugs, or have one's body entered without the right holder's
consent or permission.
Secondly, to have rights implies that other relevant persons have corresponding
duties to comply with the terms and provisions of one's rights. If a client has a right
to a vaccination, health professionals have a duty to administer it and are - in Ai-
ken's and La Follette's terms - "on a leash" held by the right holder, which man-
dates their compliance [13J. As Feinberg puts it, "rights are necessarily the grounds
of other people's duties" [14]. A third condition of any right is that rights purport to
be consistent with rationally defensible principles of justice [15]. Rights thus imply
freedom, duties, and justice.
3 Option Rigbts and Subsistence Rigbts
Among rights of an important kind based on freedom, duties, and justice are human
rights. Human rights are the union oftwb kinds of rights: option rights and subsis-
tence rights. Rights used to be regarded since around 1450 as rights to be free from
interference or as negative rights. But in the late 1840s a distinctly different kind of
right emerged: a right to receive social and economic assistance, sometimes called
subsistence rights or positive rights. These rights have some strange and assorted
sources, one in the development of the right to education and another in the right to
health care. These rights developed in Germany and in the United States. From
1920 on, this second kind of right came from eastern and western socialist countries.
The United Nations' Universal Declaration of Human Rights (1948) [16J expresses
an accomodation between these two kinds of negative and positive rights. Arti-
cles 1-21 express traditional rights, such as the right to vote, to worship, to free
speech, to a free press, and to free choice. These are sometimes called option rights
or self-determination rights and, importantly, include the right to give informed
consent. But Articles 22-27 of the United Nations' Universal Declaration of Hu-
man Rights express the right to receive social and economic resources, including
food, clothing, shelter, health care, and education, at public expense.
Since we cannot live by freedom alone, to have rights of value is to have rights to
needed resources as well. Human rights serve, in J. Nickel's terms, "as an indepen-
dent standard of political criticism and justification" [17J. One may appeal to hu-
man rights - rights shared equally by all human beings - to annul, cancel, tran-
scend, or override all rights that conflict with them. Human rights set standards for
the critical evaluation and justification of social, educational, and health care prac-
tices. To have human rights provides an injunction that gives public notice that the
burden is placed on all those who attempt to justify exceptions to, infringements up-
on, and abuses of commonly accepted standards.
A strength in appealing to human rights in health care, then, is that rights pro-
vide moral buffers against unjustified forms of interference, neglect, or deprivation
by others. A client who has rights may give or withhold consent, and it is mandatory
18 B. Bandman
for other relevant persons, to comply with a client's rights. A nurse, such as Nurse
Ratched in K.Kesey's One Flew Over the Cuckoo's Nest [18], has no right to coerce
a patient, such as McMurphy, to take his pills.
A central issue in the ethics of nurse-patient relationships concerns the relation
between negative and positive rights. Some writers identify rights with negative
rights only, rights to be left alone, to choose, regardless of consequences, but not too
much else. If a person is helpless, too bad for him or her. On this view, no one has a
right to be given help. The single principle of one's right to decide what happens in
and to one's body or to express one's belief that one owns one's body and one's be-
liefs seems to be the metaphorical analogy that covers one viewpoint concerning
some of our remaining, more intransigent cases.
The view invoked in defense of one's right to control what happens in and to
one's body and one's beliefs has recently been called the "will" or "choice" view of
rights [19], an unduly stout form of antipaternalism. That view seems morally im-
poverished, for it fails to account for a person's incapacity to express option rights if
a person is either too poor, too sick, too unenlightened, or too powerless to express
autonomy or self-determination rights. There are cases in which a person does not
know best and in which he or she" needs help to make the wisest decision. In an im-
portant paper, Elsie Bandman cites an example of a would-be suicidal patient
whom the nurse saves from death by preventing the patient from plunging out of a
22nd-story hospital window [20]. This does seem to provide a counterexample
against identifying a client's right by doing whatever the client wants to do out of his
or her own choice and not ever restraining the client.
There are limits, however, to one's autonomy. Identifying one's rights with one's
will and desire exclusively is not the only way to decipher one's most vital rights.
One may also connect one's rights to one's best interests. There are grounds of justi-
fied interference with one's liberty both for one's interest and for the good of others.
One may be restrained from unknowingly harming oneself, such as taking medical-
ly inadvisable forms of treatment. One may also be counseled to take appropriate
measures to prolong one's life, where the evidence on behalf of the viability of one's
life warrants doing so.
Recently, D. N. MacCormick developed a distinction between a "will-based"
view of rights, which emphasizes values associated with freedom, and rights of an-
other kind, an interest-based view, which emphasizes benefits conferred equally on
all persons, regardless of the capacity to exercise one's will [21]. The United Nations
Universal Declaration of Human Rights shows that Articles 1-21 are oriented by a
will-based view, whereas Articles 22-27, which include the right to a decent stan-
dard ofliving and the right to health care for everyone, are oriented by an interest-
based view. Rights of this kind have a crucial bearing on deciding quality-of-life is-
sues quite differently from deciding under the influence of the will-based view of
rights.
To show how subsistence rights may have priority over option rights in crunch
cases leads us to consider our remaining cases, one of which is about Edward, a
high-anxiety cardiac patient. If one believes in the moral priority of preventing
harm, a case may be made, it seems, showing that the health team is well within the
bounds of respecting the fundamental interest-based rights of the patient, to with-
hold information from the patient. The right to live and not be seriously harmed, on
an interest-based view of rights, is even more fundamental in a pinch than the right
to remain free. If a wise nurse knows that there is still a viable and enjoyable life to
be lived in which the patient who is prevented from harm or death could retrospec-
tively after a time say, "Thank you for not listening to me when I wanted to refuse
help," then we do not think such a nurse has wronged the patient. On the self-deter-
mination view, the nurse will be apt to perceive herself as the servant and instrument
of the patient, willing dutifully to assist the patient and to take the client as his or her
word. It may sometimes, however, be better for the nurse to perceive herself as a
friend of the client, in Aristotle's sense, one who cares with intelligence and wise
judgment. Ordinarily to deprive a person of rights is to do something wrong to that
person. But that can't quite be said about a nurse who saves a would-be suidical
person whose life is still viable. If a nurse saves a suicidal patient's life, refusing to
help carry out the patient's wish of the moment, what will be our attitude? Would it
be to condemn the nurse for refusing to pay attention to the patient's will? If the
patient could conceivably be grateful afterwards for having been saved, we do not
think such a nurse could seriously be said to have wronged the patient. 3 One could
thus set aside a patient's will-based rights by considering a person's own, more fun-
damental, deep, interest-based rights that are preemptive, that, in a manner of
speaking, shine over all else.
We come now to perhaps the most difficult case, that of the craniotomy patient.
Here the patient asks the nurse not to save her life under certain conditions. To com-
ply with this patient's right to die requires the nurse, on one view, to commit murder.
But is it murder? In one sense, to destroy or fail to save a human life is a serious
wrong, but not if that life is no longer a gift to that person. A human life ceases to be
a gift if it no longer has humanly worthwhile prospects. We know when we have the
considered judgment not only of the afflicted but the judgment of all those who
seriously attend the plight of those whose lives are no longer gifts but unbearably
painful burdens filled with suffering, anguish, and torture. In hopelessly terminal
cases, if we consult the patient's most fundamental interests as friends (in Aristotle's
sense), we might then recognize that since their life prospects are hopeless, we, were
we in our friend's place, would regard a further prolongation of a human life as no
longer perceivable as a gift. To be a friend in that type of hopeless case is to help,
even if it means ending our friend's life, as Freud's physician was willing to do. If a
nurse does not resuscitate a craniotomy patient who asked not to be resuscitated, I
think that under certain retrospectively verifiable circumstances, we would not
think it wrong.
The kind of rights this appeal might require is not the older, political liberty or
option rights view, which says, "Don't interfere," but the newer one which says,
"Help me; assist me." A view of rights which addresses a client's or nurse's vital, ra-
tional interests seems the more adequate at such a time. These deeper subsistance
rights to live well are most closely associated with social and economic justice and
provide the conditions for the subsequent effective exercise of self-determination
rights.
3 We may call this a retrospective analysis of patients' and nurses' rights. Those who don't object to
counterfactual conditionals will find this analysis congenial
20 B. Bandman
4 Conclusion
In this paper, I tried to show that patients and health professionals have limited hu-
man rights, that such rights are the union of option and subsistence rights, and that,
in a pinch, subsistence rights are preemptive4 or exclusionary5 in that such rights ex-
clude and override all other value considerations. To show whose rights to take seri-
ously in these cases, several recent philosophical moves were described and dis-
cussed: the quorum feature notion, tracing viewpoints to their metaphors and
examining the extent of their applications and the biological/biographical/social/
cognitive distinction.
Rights are important to all people. Rights provide people with dignity and self-
esteem, as well as sustenance and fulftllment. In the constellation of values enriched
by human rights, freedom to choose is an important part of the rights of patients
and health professionals, but as D. N. MacCormick points out, it is not the only
right. The right to be helped to live a decent and fulfilling human life [18] is also
good; and in a pinch, the defense of this other right may matter even more than hav-
ing a choice.
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5. Will GF (1980) Newsweek, April 14, p 112
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Nurs Sci 1/3: 27
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pp 71-73
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Whats Wrong About Rights
M.Levine
The rights of the individual are perceived as natural, self-evident, and inalienable -
necessary fulfillments of human needs which are universally shared by all persons.
They are defined as the guaranteed privilege of access to the individual's fair share
of the community's wealth. Rights make certain the accessibility of adequate food,
shelter, health care, schooling, and the means to procure the rewards of success: the
symbols and gadgets of affluence. Rights also include intangible prizes - the free-
dom of speech and worship and assembly, due process, protection of one's person
from all threats, and reasonable assurance that everyone will be treated with dignity
and respect.
The certainty of each person's selfhood is translated into the language of rights.
And still, there is no certainly that every person will receive his portion. The faithful
dependence on the Bill of Rights ip the United States does not exclude the fact that
there is a continuing struggle to define individual rights in the face of repeated chal-
lenge. The government is enjoined against interfering with the freedom to speak,
but time and again the right to speak freely must be reasserted, often in the courts.
The unhappy fact is that "rights" are not God-given at all, but rather the product of
very imperfect, human determinations. Rights can be given and they can be taken
away. Laws can be written and they can be repealed 1 There is confusion between
the legal nature of rights and the ethical imperatives of health care. Legal and ethi-
cal are not necessarily equivalent, and declaring them so does not serve the best in-
terests of patient or practitioner.
The most grotesque example of the consequences of such an error in discrimina-
tion was the "lawful compulsion"2 of the Jews of the Holocaust to submit to so-
called medical experimentation by German physicians and nurses [2]. The Jews
were legalized victims because the Nuremberg Laws of 1935 had made them non-
persons. Stripped of all rights, including sovereignty over their own bodies, they
could be used as laboratory animals without the least challenge to the conscience of
the so-called experimenters. To this outrage another was added: the "doctor trials"
at Nuremberg which legitimized so-called medical excesses, as if the performance
of those vile and obscene deeds had any relevance whatsoever to medicine.
1 "The rights persons have, hold or possess have been given or granted by a legal system .... Rights
conferred ... are not ... fixed or final ... one can lose one's rights. Rights are revokable (sic)." See
Bandman and Bandman [1]
2 The word "lawful" lends awful legitimacy to these criminal events. Many authors have reduced the
facts to banality. See Beauchamp and Walters [3] "Since the Nuremberg Trials, no aspect of human
experimentation has received greater attention than the issue of consent. In the Nuremberg code
itself consent is discussed in the first and longest article."; Rutstein [4] "The human experiments
performed by the Nazis during world war II horrified the world because they were designed to ans-
wer unethical questions"; McCormick [5] " ... there has been a gradual move from the absolution
represented in the Nuremberg code to the acceptance of proxy consent possibly because the Nu-
remberg code is viewed as containing, to some extent, elements of a reaction to the Nazi experi-
ments"
Whats Wrong About Rights 23
It is difficult to understand why the physicians who invented the most exquisite
tortures on helpless persons were accorded the dignity of a trial based on the suppo-
sition that they had merely performed bad experiments. Indeed, the most immoral
aspect of the Nuremberg doctor trials was the serious introduction of debate by de-
fense attorneys (carefully guarding the rights of their clients) that sometimes indi-
viduals may be sacrificed against their will for the good of the state; that military
service was no different than involuntary assignment to medical experiments; or, in-
deed, that the historical evidence proved that protocols of individual rights were fre-
quently trampled by medical experimenters in other times and places and abund-
antly reported in the literature [2, p 320].
Even though the court found most of the defendants guilty, the larger share of
guilt belongs to the society that condoned the separate treatment of physiciatls as if
they had any-claim to scientific legitimacy. There has been a continuing reinforce-
ment of that disgraceful decision by the frequent citation of the Nuremberg doctor
trials as the basis for present-day rules of informed consent. Such an interpretation
of those events serves only to reinforce them as rational and acceptable - and they
were neither. Nor is there any comfort in the contention of many writers in bio-
ethics, to quote one, that " ... no human action before or since parallels (the Nazi)
degree of evil" [6].3 To point to the Nazis simply as examples of the depth of the de-
pravity to which man might sink is to bear false witness against the Jewish people
and their history, because the depravity so methodically demonstrated by the Ger-
mans was taught to them by generations of haters, defilers, and murderers of Jews.
They had excellent models of bestiality, and they learned their lessons well.
It is pitiful that one must cite Nazi excesses in the name of medical experiment
to raise, as one author says, "The consciousness of the public about what human be-
ings are capable of doing to each other in the name of medical science" [6]. It is
naive and ignorant to invoke those events in order to receive the lesson of man's in-
humanity to man, and none are served by reciting the litany of the misguided re-
search of others - which was, in fact, misguided but not malicious - as a means of
softening the full impact of the abominations performed by Nazi doctors and Nazi
nurses on Jewish people. We owe no debt to the Nazi doctors. They did not teach us
of evil merely, nor did they teach us, through their awful example, of the proper pro-
tocol for human experimentation and treatment. 4 They taught us only how easily a
silent world could tum its back on their victims, pretending to this day that there
was a medical excuse for their deeds and thereby enlarging the awful silence. 5
3 See also vaux (7) "The most important ethical insight from Neuremberg (sic) is the reminder it gives
to the potential evil in man. The experience serves as a constant refutation of the myth of inevitable
progress" and Davis and Aroskar[8) "The single most important ethical insight (of the Nuremberg
code) is that it reminds us of the potential evil in human beings and serves to constantly refute the
myth of inevitable progress"
4 Even so prestigious and germinal a work as Paul Ramsey's [9) assumes without questioning, the va-
lidity of " Nazi experiments" as ajustifiable basis for the "Nuremberg Code". Attributing initial au-
thorship to Dr. Leo Alexander, he regrets only that the Tribunal excluded Dr. Alexander's "proxy
clause". "The Nazis simply were not doing beneficial research," writes Ramsey
5 The apathy, indifference, and silence of the nations of the world has become the subject of a gro-
wing literature. One of the earlier works was Arthur Morse [10). More recently Walter Lacquer [11).
The revisionists who now purport to "prove" that the events ofthe Holocaust are Jewish fantasies
stand on the indifference of the generation of silent witnesses
24 M.Levine
If we had no instruction but this from which to create the rules of behavior that
regulate the joining of physician and nurse to the patient in shared purpose, we
should be gravely hampered in establishing a structure of health care. Surely the
tenets of ethical conduct are not produced by the most evil of men, but rather are
the consequences of kindness and caring, as much natural attributes as the desire to
cause harm and suffering. There is a potential for evil in man, but there is also a po-
tential for good. It is one thing to base on ethical position on the only proper de-
fense of the ancient, but primitive, physician, who, using the rule to "do no harm,"
avoided the consequence of his own ignorance. But it is no longer sufficient to "do
no harm."
Now we posses the instruments, knowledge, and technologies for controlled,
successful interventions and "harm" has become a potential consequence of both
omission and commission [12].
The basis of relationship between practitioner and patient must come from a
fundamental source of decency and mutual respect, a decency founded on the exis-
tence of an abiding trust in the good will of each for the other. Individual rights have
validity only in context because through such rules the community brings justice
and order into the lives of all of its members. Learning to venerate the rights of oth-
ers comes from caring. In Gaylin's words:
... the protective, parental, tender aspects of loving- ... a part of relationship
among peers, child to parent, friend to friend, lover to lover ... The linkages be-
tween being cared for and caring for others are crucial ... [13, P 33]
There is no sense to health care which ignores that "linkage." But the inviolability of
individual rights has become the canon of modem health practice. In defense of the
rights of individuals, elaborate systems of monitoring and control have become
commonplace. The protection of rights has evolved into a complex bureaucratic
machine, living a life of its own. Dedicated to the proposition that evil organizes re-
lationships, it is as if the Nazi doctors stood at our side, directing us to distrust our
own best instincts. When defense of rights becomes the voice of hostile and aggres-
sive intentions, then the ghosts of those monsters must celebrate, indeed. And car-
ried to its ultimate excesses, "rights" may become the weapon with which decency
itself is destroyed.
What motives are served in the warning Glasser addresses to us to " ... respond
to the claims of service professionals as if they were cops" [13, p 124]. Both the so-
cial worker and the policeman serve "important social ends," he says, but "both are
dangerous. Both will violate rights in the course of their jobs if they think it is im-
portant enough, and therefore that is a decision that cannot be left to them. "Cops and
social workers, says Glasser, are " ... not the guardians of their client's liberty." Ex-
actly so. The service professional is only the guardian of the patient's dependent
need in every instance where an individual has presented himself for help. It may, in
fact, be more accurate to say that it is becoming necessary to guard the patient from
interference with appropriate care instigated by his lawyer.
In a way never intended, the very rules which were designed to safeguard and
protect the interests of the patient now pose a threat which increasingly thwarts the
care process. Rules restricting the behavior of the physician and the nurse affect
therapeutic protocols as well as research designs. Health professionals know full
well that the patient does not discard his rights with his clothes on admission. But
he also has not entered the caring relationship to confront and confound the service
professional. He has come to fight only that which has disabled and discomfited
him, anticipating justly that he will be met by physician and nurse in a spirit of con-
cern and service. Nurse and patient cannot be adversaries and no outside source
serves either one by creating an adversarial confrontation. Glasser has called the
patient a "Prisoner of Benevolence" but he is prisoner only to the pathophysiology
that requires the intervention of the nurse. Only the awful emphasis on evil inten-
tions could have turned the two words "doing good" into a nasty threat [13].
The real world is often cruel and unjust. But how is that changed when the de-
sire to reach out to each other requires first that we analyze each act to be certain it
conforms to the statutes? Yet that has often been the effect of the excessive move-
ment of legal restraint in the therapeutic relationship. Is the patient really served
best by "defensive medicine"? Must the lawyer's shadow fall constantly on the
nurse's interaction with the patient? Have the Nazis thought us only to be suspi-
cious of each other, even in those professional roles which are dedicated to the ser-
vice of the sick and disadvantaged?
The individual practitioner is permitted the freedom of his art and science with-
in the social restrictions created in the laws that license and regulate it. Society
creates the ground rules for practice, but the professional demonstrates his compe-
tence - even his minimal competence - as the price for the performance of his craft.
Professional practice acts should be the product of a trusting relationship between
the practitioner and the community he serves. Thus a practice law that is the careful
result of collaboration between the lawmaker and the professional creates the limits
on the rights of the practitioner and thus guards the welfare of the community. In-
competence cannot be tolerated, nor, indeed, any act which compromises the law. If
the licensed practitioner cannot be trusted to fulfill his obligation under the law, he
should not be licensed or his license should be removed. Such laws exist, some less
perfect than others. But protecting the rights of the patients does not come from a
failure to properly restrict the service professional. It is rather a failure to enforce
the laws already established. While professional disciplines have the responsibility
to police themselves and demand not minimal, but optimal, performance, the enfor-
cement of the law is as much the community's concern as it is that of the profession.
The imperfect way in which regulatory laws are enforced suggests that passing new
restrictive laws will hardly improve the protection of the patient's rights. Beyond
that, the individual who is licensed to practice does not become immune from the
same restrictive laws that all citizens must obey, nor does he relinquish his share of
protection under the laws that sustain his well-being. Clearly the recent statements
that purport to guarantee "rights" to selected populations - such as the American
Hospital Association's "Patient's Bill of Rights" - were redundant statements re-
flecting legal restraints on practice already well established.6
And the lesson of Nuremberg tells us that when the laws are changed, however
arbitrarily, no degree of committment to human dignity will protect the victimized
popUlations. Finally the exercise of respect depends on the individuals who meet
each other at a mutual level of concern. Historically, nursing traces its lines from the
6 Many authors have directed attention to the redundancy of this document [14]
26 M.Levine
nurturing process, that relationship which Gaylin called "caring." Nursing has been
constantly renewed by individuals - men and women - who sought for themselves
the caring role fostered by their belief in human service. The formal education of
the nurse provides the individual with the instruments and knowledge of caring, but
the way it is used by each person depends upon his personal values. Certainly we
are long past the naIvete of that time when the "good nurse" was described as a
"good person" and that sufficed for the moral imperatives of caring [15]. Now
nurses are exploring their ethical beliefs, learning to challenge each other, and ex-
amining in discourse the motivations, dedications, and decisions which have been
the substance of practice of individual nurses.
But the dialogue has barely begun. Preoccupation with ethical dilemmas has
served only to emphasize how intensely personal the preferences of individual
nurses are, coming not from the convictions of the professional role, but rather from
a stirring of unexamined individual belief. The dilemmas of health care will not be
resolved by professional practitioners alone, but in concert with all of those in the
community whose interests are challenged. But the nature of nursing care is the
proper concern of professional nursing, and the examination of its ethical nature
must be seriously addressed.
Perhaps the most urgent moral issues in nursing occur in the daily interaction
between nurse and patient in whatever environment their meeting takes place [16].
It is reflected in the common courtesies exchanged between the patient and the
nurse: the respect for privacy and person, the patience and forbearance of the care
giver with the irritability and discomfiture of the care recipient. It mirrors the cau-
tion and concern of the nurse who has not only prepared well the ministration or
treatment to be performed, but has prepared the patient equally well so that he un-
derstands the intent and participates as a full partner with veto privileges. It is the
ready use of compassion applied with equal fullness for all persons, but especially
those who disappoint the nurse by intransigence or a life-style that suggests he is his
own victim. It is the dedication to truth-telling, recognizing the dignity of every indi-
vidual and all who care about him: family, friends, community. And often it is the
ordinary, mundane, casual exchanges when the patient and the nurse, trusting each
other, pose no threat to the rights each possesses because they are sharing a human
moment that will enlarge the good in each of them.
References
1. Bandman EL, Bandman B (1978) Bioethics and human rights. Little, Brown, Boston, p 39
2. DonaganA (1977) Infonned consent in therapy and experimentation. J Med Philos 2/4:
307-329
3. Beauchamp I, Walters L (1978) Contemporary issues in bioethics. Dickenson, Encino, p 402
4. Rutstein D (1969) The ethical design of human experimentation. Daedalus 9812: 528
5. McConnick R (1974) Proxy consent in the experimentation situation. Perspect BioI Med 18: 1
6. Fromer M (1981) Ethical issues in health care. Mosby, St Louis, p 272
7. Vaux K (1974) Biomedical ethics: morality for the new medicine. Harper and Row, New York
8. Davis A, Aroskar M (1978) Ethical dilemmas and nursing practice. Appleton-Century-Crofts,
New York, p16
9. Ramsey P (1970) The patient as person. Yale University Press, New Haven, p 26
10. Morse A (1968) While six million died. Random House, New York
11. Lacquer W (1980) The terrible secret. Little, Brown, Boston

12. Levine ME (1976) On the nursing ethic and the negative conunand. Proceedings of the intensive
conference of the faculty of the University of Illinois at the Medical center society for health
and human values, Philadelphia
13. Gaylin W et al (1978) Doing good the limits of benevolence. Pantheon, New York
14. Gaylin W (1978) The patient's bill of rights. Contemp Issues Bioethics 141-143
15. Ingles T (1959) What is good nursing care? Am J Nurs 59: 1246-1249
16. Levine MG (1977) The nursing ethic and the ethical nurse. Am J Nurs 77: 55
Medical Care: The Problem of Autonomy
U.Lowental
People sacrifice some of their autonomy by becoming patients. Therapist-patient re-

lations may involve a greater or a lesser degree of such intrusion. Therapy may be
like a mutual participation, with patients consulting us only occasionally, as is the
case between adults. At times it may be a guidance-cooperation with patients who
continue to excercise some judgment, although required to comply, as it is with ado-
lescents. Often it is more of the activity-passivity type and patients are treated as if
they were children.
A patient's best interest require that we disregard his self-determination. Thus,
we shall withhold any water from the lips of the thirsty, dehydrated accident victim
who is wheeled in for surgery, and we must perform a painful change of dressings or
a cystoscopy or a lumbar puncture, despite patients' painful outcries or their plead-
ing for mercy.
Patients are denied the right to be impatient, and they are hardly granted the au-
tonomous choice whether to give or to withhold their consent to treatment. Minors,
mentally sick, or comatose or dYulg patients are usually overruled. Medical care in-
volves additional, insolvable dilemmas. For instance, what should be done when a
"terminal" patient has to be removed from a bed in the intensive care unit to make
room for a recently injured, comatose young driver? Or: do patients really have the
autonomous right to sign a "living will", requiring, for example, that all treatment
be stopped in case of a bronchogenic carcinoma or bilateral inoculation?
Do we always have the advantage of greater objectivity to justify our "medical
paternalism," our withholding the truth from patients and disregarding their auton-
omy in many other respects, too?
The issue is quite complex, since autonomy is, in fact, relative. Even the frank,
recordable, and measurable freedom from external control is relative, as we have
seen more than once when a wounded prisoner-of-war was returned from captivity
to his homeland hospital. They greet their recovered freedom, even though they
may now be chained and suspended in a plaster cast, with tension devices and infu-
sions.
Internal forces, like drives or psychological recoils, affect the autonomy to a sim-
ilar, or even greater, extent, as is known to everybody. Beyond this, we have the un-
alterable genetic endowment: one cannot decide upon one's height, one's intelli-
gence quotient, factor VIII deficiency in hemophilia, or the extra chromosome in
Down's syndrome (mongolism). There seem to be no real autonomy from one's self
- or from fate. The membership in a certain minority group, or the winning of a mil-
lion dollar prize; these affect one's life and health but are certainly the result offorce
majeure.
The call to observe autonomous decision making and to respect each individu-
al's tradition seems almost axiomatic. With geriatric patients, for example, thera-
peutic compliance is enhanced by a careful attention to their life-style and habits.
Demands which ignore these may appear to them as violation of their autonomous,
Medical Care: The Problem of Autonomy 29
well-established identity, creating a distress even worse than the original disease for
which they had come for treatment.
On the other hand, many patients feel uptight, helpless, and depressed. Emo-
tionally, they regress into an infantile dependency, so that quite often they seek no
autonomy, but - on the contrary - they welcome any opportunity to delegate all de-
cisions to the doctor or the nurse. They want help rather than autonomy, hence our
excessive regard for the latter might actually go counter to their free choice! It seems
we all need a true skill of empathy to handle such complex situations.
What about the autonomy of the therapeutic team? The institutional hierarchy
with its division of roles and responsibilities leaves only a narrow margin of autono-
my to each nurse or physician. It reminds me of the Orthodox Jews' code ofbehav-
ior, the Shulchan-Aruch, which covers and guides us everywhere. Medical ethics
leave very little leeway even in a solitary private practice, since many decisions must
choose the lesser evil out of several equally justified alternatives.
Furthermore, each one of us is biased in his or her evaluation of patients. One
feels a greater empathy for old patients or for the very young. Some prefer patients
of their own ethnocultural background or only those who display a genuine agony.
There is the bias of one's medical Weltanschauung: Do I usually administer only the
minimal necessary treatment in order to foster patients' autonomous striving for
health, or do I use each opportunity to interfere with a patient's bad habits, accord-
ing to the principles of preventive and holistic medicine?
In conclusion, we health professionals find autonomy to be a complex, dynamic
parameter of therapeutic transactions. Many of its multiple levels are concealed,
preventing a direct observation and requiring our inferential reasoning and a care-
ful, self-conscientious scrutiny. Paradoxically, some of these aspects must be dealt
with in an illogical, intuitive fashion. Thus, patients are encouraged to regain a full,
autonomous health. Ifwe respect their autonomy, we may assist them in another di-
rection too, as it was pictured by Emily Dickinson:
The heart asks pleasure first,

and then excuse from pain,
and then those little anodynes
that deaden suffering.
And then to go to sleep,
and then if it should be
the will of its Inquisitor
the liberty to die [1].
Rights and Responsibilities of Nurses as the Basis for Their
Contracts with S?ciety, with Patients, and with Colleagues
M.J.Flaherty
1 Definition of Nursing
Whenever nurses meet, they express concern about the quality and quantity of their
professional practice. One always tries to defme nursing. Florence Nightingale was
the first (and perhaps the last!) nurse to believe that she had done this. Since her
time, many definitions of nursing have been proposed, but most lend clarification to
what nurses do rather than what nursing is.
One Canadian nurse works with a statement about nursing that constitutes a
definition of it. Doctor Marian McGee, Dean of the Faculty of Nursing at the Uni-
versity of Ottawa, describes nursing as a process of nurse-patient interaction that
stems from the assessment of a plltient's needs and levels of functioning and that is
designed to optimize the patient's adaptability through modification and/or rein-
forcement of the environment, modification and/or reinforcement of behavior, and
biological care and maintenance. The process can be accomplished through the use
of nursing care strategies in appropriate measure (M. McGee 1975, personal com-
munication). This definition says what nursing is and what nurses do. It incorporates
the notion that nursing practice focuses on the promotion of optimal health for in-
dividuals and families. Health is a manifestation of the competence with which in-
dividuals and families function. States of health vary according to the efficiency and
effectiveness with which individuals and families interact with their environments.
Hence, health states are measures of functional competence. It follows that if the
aim of nursing is to promote functional competence, nurses in various settings must
be well versed in the knowledges, the techniques, and the conceptual and theoreti-
cal rationales that underlie nursing practice. One might wonder whether nurses are
qualified for such work.
2 Professional Status of Nursing
Nurses of the 1980s have declared that they are professional and that they want to
embrace the privileges and responsibilities of professional status. Like other health
care workers, nurses are faced daily with complex issues and are called upon to
make far-reaching decisions. Members of our society believe that professional
nurses possess certain characteristics that have prepared them to exercise their
proper roles as citizens and as health care professionals [1].
The first of these characteristics is education, both general and specific. General
education equips nurses to think and reason with accuracy and to appreciate the
world in which they live and work; specific education gives them a theoretical
framework for their practice. Nursing education programs are designed to meet the
needs of students in the light of the professional demands that are expected to be
placed upon them in the health field.
Rights and Responsibilities of Nurses as the Basis for Their Contracts 31
A second characteristic of the professional nurse is acceptance of a code of eth-

ics. The high value that nurses place on the worth and dignity of human beings di-
rects them in their practice. As certain elements and characteristics of society
change and as roles of people, including professionals, are altered, ethical codes
may be subject to modification. The basic quality demanded by a code of ethics is
integrity; that means "doing what one believes to be right, regardless of the cost"
(P. Maloney 1962, personal communication). Belief in something implies that a per-
son has given careful thought to the information at his or her disposal and has ar-
rived at a logical conclusion. Beliefs may be modified in the light of new evidence
and the nurse with integrity has the courage to change his or her mind. However, as
Marcus Aurelius has warned us in The Meditations; "But this change of opinion
must proceed only from a certain persuasion, as of what is just or of common ad-
vantage, and the like, not because it appears pleasant or brings reputation" [2].
A third characteristic of nurses is dedication to the ideal of master craftsman-
ship in their work. In The Metaphysics, Aristotle noted that "the master craftsmen
are superior in wisdom, not because they can do things, but because they possess a
theory and know the causes" [3]. True mastery of nursing is not something that is
acquired suddenly, rather, it is an ongoing process that demands of nurses that they
strive constantly to add to personal knowledge, to perfect professional skills, and to
enlarge the body of knowledge for the' discipline. Florence Nightingale is said to
have stated that "Nursing is a progressive art in which to stand still is to have gone
back. ... Progress can never end but with a nurse's life" [4]. The hallmark of a master
craftsman in nursing is an enquiring mind and a commitment to continuous learn-
ing.
A fourth characteristic of professional nurses is informed membership and in-
volvement in the organized profession. Nurses who are intellectually self-employed
think and speak for themselves and act according to their own decisions rather than
according to what someone else has told them to do. Nurses with enquiring minds
know what is going on in the profession and are involved in the development of
new patterns. They will not tolerate the absolutism that could result if, as members
of a "tired democracy", they fail to participate.
The final characteristic of professional nurses, subsuming the other four, is ac-
countability or the taking of responsibility for one's own behavior. Nurses do not
blame others for what is done or not done in the profession and in the society in
which they live and work. Rather, they participate in decision making and live with
the decisions. They accept the fact that, over time, they will experience both failures
and successes but they believe that if they act responsibly, their successes will out-
number by far their failures. These nurses strive constantly to practice in a diligent,
reasonable, and justifiable manner; they document their rationales; and they are
willing to subject their practice to the scrutiny of their peers. Feeling no obligation
to shoulder the burden of omniscience, they develop and apply strategies to deal
with the almost instant obsolescence of knowledge and professional practice and
achieve Dag Hammarskjold's "Maturity: that means among other things - not to
hide one's strength out offear and, consequently, live below one's best" [5]. The eth-
ical nurse's "best" involves exercise of professional practice, through application of
the nursing process, at the highest level of which that nurse is capable.
32 M.J.Aaherty
3 Standards of Nursing Practice
When persons qualify, apply for, and accept registration as nurses, they accept the
commitment to exercise generally accepted standards of nursing practice in all situ-
ations in which they agree to function as registered nurses. Statutory or registering
bodies for nurses must either develop standards of practice for the performance of
nursing services by their registrants in their jurisdiction [6] or endorse a previously
formulated set of standards [7]. This is in line with the responsibility of the statutory
bodies to protect the public by ensuring that those persons who are registered as
nurses are qualified to be so registered. It is through the establishment, mainte-
nance, and ongoing development of standards of nursing practice that the register-
ing bodies define the scope and nature of nursing practice, regulate the practice of
the profession, and discipline or investigate registered nurses about whom there is
concern. The license to practice nursing does not include a permission to practice
poorly; it presupposes an obligation to practice well. For nurses, registration in-
volves the formation of a number of contracts - with society, with the employing in-
stitution, with patients, with pati~nts's families, with physicians, with other nurses,
with health professionals in other disciplines, with students, and with other workers
within the health care enterprise. All of these relationships are crucial to the day-to-
day conduct of the work place and to the day-to-day practice of nurses.
4 Nurses' Contracts
The authority for nursing is based on a social contract under which society grants to
the profession authority over its own functions, together with significant autonomy
in the conduct of its own affairs. In return, the profession is expected to behave re-
sponsibly in accordance with the public trust. Since public and private health care
institutions offer services that are defined both by legislation and by the policies of
the institutions, the public has a right to expect that when these services include care
rendered by registered nurses, conditions will be provided under which generally
accepted standards of nursing practice can be met and indeed that such standards
will be met. This constitutes the honoring of the contract that nurses make with the
institutions. These conditions include the necessary staff and structures to make
possible effective use of the nursing process, collaboration, coordination, and com-
munication among all members of the health care team, behavior that is consistent
with relevant legislation, with appropriate codes of ethics, and with the policies and
practices of the agency, the maintenance of competence relative to current practice,
and the acceptance of responsibility for professional behavior. Where nursing care
institutions do not provide such resources, they are not fulftlling their legal, ethical,
and social responsibilities to provide health and/or illness care given by nurses and
other health professionals. They are failing to fulfill their commitments to society
individually in terms of the recipients of care and in terms of the health care profes-
sionals and collectively as part of the public trust.
Because nurses are involved with significant personal concerns of other human
beings, the foundation, form, and balance of values within the nurse-patient rela-
tionship are of great importance. Nurses view patients in their wholeness, in their
completeness as human beings - body, mind, and spirit. The relationship is dynam-
ic and may show the characteristics of all or any of these types: child and parent,
client and counselor, teacher and student, friend and friend, colleague and col-
league, and so forth through a wide range of possibilities [8]. This requires of nurses
attention to significant moral considerations, such as the individual's rights of self-
determination and bodily integrity. It is a complex relationship.
The function of nursing necessarily requires knowledge of the family as well as
of the patient. This is true particularly when the patient and/or family are caught in
the intricacies of a health problem that taxes their human relationships and coping
capacities.
Nurse-family relationships call for partnerships as a central means for the solu-
tion of problems - keeping in mind the primacy of the nurse-patient relationship,
the sharing of power, and the examination of conflicting views and the continuation
of communication despite differences in expectations. It is a taxing relationship as
nurses help families to cope in their own ways [9].
Nurses and physicians have inherited rather different basic images from history
and these images persist in many areas today with little appreciation by each group
for the other. Although they are supposed to be working on teams, often teamwork
is absent and cooperation is lacking as the "guest practitioner" physicians wield a
great deal of power over the nurses, who are regular employees of the institution.
This leads to tension and lack of mutual respect [10].
The context in which nursing practice takes place plays an important role in the
determination of the nature of nursing practice and hence of nursing care. Nurses
are employed today by many kinds of institutions, the scope and complexity of
which vary from the corporate bureaucracy that may be seen in a large multiservice
hospital to the two- or three-person community clinic or physician's office. Between
these two extremes are large numbers and types of health-related organizations in
various areas and settings. Whatever the particular employing agency, it is essential
that the nurse employee understand fully the nature, purpose, and obligations of the
employing agency in order to understand the obligations, rights, and responsibili-
ties of the nurse as employee. The trustees of health care agencies are held morally
and legally responsible for everything that goes on in the institution, including the
activities of all professionals who work in it. This corporate responsibility for the
quality of care means that the agency can expect accountability and competence
from all professionals in the agency [11].
Nurses, as members of a profession, have obligations to each other to work to-
gether to promote and foster high ideals in themselves and in their colleagues. Peo-
ple need to trust nurses, and to maintain this trust, nurses must trust and rely on one
another. To do this, they must care for each other, by helping, teaching, and support-
ing each other, in the effort to realize nursing'S commitments to society [12].
5 The Realities of Health Care Practice
The reality of today is that in health care agencies, there are tensions that lead to
conflict. Inflation and fiscal constraints are facts of life today that push nurse man-
agers to promote cost containment in the face of professional desires to maintain
34 M.J.Aaherty
high quality of service and personal needs to protect their own standards of living
[13]. Thus are nurses, at all levels, pulled to serve more than one master. As they at-
tempt to choose among them, their orientations to their discipline and/or to their
employing institutions may be disrupted [14].
Because registered nurses, by the very nature of their profession, are required to
exercise judgment in the carrying out of their duties, there may be instances in
which the institutional goals or directives seem to be at odds with nurses' profes-
sional judgments. However, just because a nurse is a professional with the capacity
for judgment, he or she does not cease to have certain responsibilities, as an em-
ployee, to the employer. In most collective agreements, for example, it is recognized
explicitly that there are institutional goals and that an employer is not required to
shut down his institution during discussion of a difference of opinion. Attempts are
made by nurse managers in health care situations to operate the institution in the in-
terests of both parties to the dispute.
, In a health care agency, however, there is a third set of interests that are para-
mount to both employers and employees; they are those of the patients or consum-
ers of the health care delivered by the agency and its employees. For example, what
happens to the patient when a hospital unit has too many acutely ill patients for the
too few nurses who are assigned"to the unit? That situation may occur when the ad-
ministration of the hospital realiZes that in order to stay within its budget, it must cut
nursing staff. How can the agency provide health care that is appropriate and that
includes skilled nursing care when there are too few nurses to provide any kind of
nursing care, let alone skilled nursing care? All too often, the nurses in the situation
have little or no voice in the determination of work loads.
How are the patient's interests protected when nurses in a situation believe that
a patient has not given a fully informed consent to a procedure such as surgery? In a
situation reported by a nurse who spoke from the floor at the International Con-
gress on Criticial Care Medicine in Washington, D. C., during the month of June
1981, that nurse, having reported her concerns to both medical practitioners and to
her superiors in nursing, and who was told that since a consent form had been
signed by the patient, she should prepare the patient for surgery, refused to do so on
the grounds that she believed the patient did not realize the nature and scope of the
surgery. The nurse was disciplined by the agency and failed to win the support of
her registering body. She believed that had she prepared the patient for surgery and
taken her to the operating room, she would have been in contravention of the stan-
dards of nursing practice that included patient advocacy, and for which she was ac-
countable.
- What happens to the interests of the patients if nurses are told to carry out physi-
cians' orders about which they have concern? Very often nurses are told simply to
obey the order involved and that the physician will accept responsibility for the
nurses' actions. Responsible registered nurses know that since they are always ac-
countable for their own behavior, they share responsibility and guilt in the carrying
out of an inappropriate order. In Canada, a number of the nursing statutes are ex-
plicit in the requirement that nurses question directives, policies, or practices about
which they have concern. In spite of this, a great many nurses today believe that
they are able to be directed by other health care professionals. Although this may
not be as great a problem in Canada as it is in some countries,even there nurses of-
ten find themselves in situations in which they have limited authority, and when
they attempt to exercise their broad ethical and legal responsibilities to and for pat-
ients, they feel powerless, excluded, and dependent if there is lack of nurse/physi-
cian collaboration and cooperation. Frequently, nurses are accused of being defen-
sive when they insist that nurses be responsible for nursing, even though nurses'
responsibility for their own behavior and for the regulation of their own profession
is explicit in many nursing statutes. The nurse of the 1980s is responsible for profes-
sional judgment at two levels:
1. At that of a professional who influences and promotes change in health care poli-
cies in national, provincial, state, and local domains and who has input to policy
decisions and to the establishment of standards in the profession at large and in
the employing institution and
2. At the level of an individual practitioner - who may be a clin!cian, an administra-
tor, a teacher, or a researcher - who is responsible for the quality of care provided
for individuals, families, or groups.
Nurses' attempts to exert leadership in these areas for which they are accountable
are met often with opposition from physicians, some of whom perceive nurses to be
encroaching on their "professional territory", and some of whom reject and may
even try to block the attempts of nurses to move beyond the "caretaker" role and to
enter the traditionally physician-oriented, "healer role" that has been directed tow-
ard the tasks that are necessary to restore an individual to a functional status. This
goal, as carried out usually in a specialized health setting, has evolved into the tradi-
tionally masculine and medical role.
Some blurring of roles and overlapping of responsibilities and areas of function
can be expected in situations where two professions such as medicine and nursing
have the same clients and the same type of interests in those clients, that is, the
promotion of the well-being of individuals, families, and communities. The practice
entailed in such promotion necessarily involves intervention in the lives of others.
Hence, it has an ethical component, whether the practice is direct patient care, the
teaching of those who will enter the profession or who will increase their compe-
tence in it, and/or the advancement of the theoretical aspects of the profession
through research involving individuals or groups. Ethical decisions that are based
on values are made by these health care professionals. Their ability to fulfill their
ethical responsibilities depends on the professional contexts in which nurses and
physicians work: appropriate professional preparation, suitable conditions for the
exercise of professional practice, social respect for the professional as a decision
maker, and social recognition of professional expertise [15].
The ethical judgments made by nurses and physicians flow from personal con-
science and include a weighing of alternatives - what could be done - and the mak-
ing of decisions - what should be done. As alternatives are weighed, past experi-
ence, possible consequences, and personal strengths and weaknesses come into
play. Once the decision is made, personal inventiveness and strength of will are im-
portant in the implementation of the action that flows from the decision [15]. Al-
though nurses and physicians pride themselves on their sensitivity to cultural and
family factors that influence patients' problems, what do they do when the patients'
wishes and values are in sharp conflict with those of the health professionals?
36 M.l.Flaherty
Whose values should take priority? If the health professionals' values take prece-
dence, how does this affect the patient-professional relationship? On the other
hand, if a patient's values take precedence, how does this affect the professionals'
responsibilities to practice their profession and to care for the patient in the way
that they believe is best for the patient [16]? How can health professionals make de-
cisions that may be advantageous to their patients but a burden or a strain on soci-
ety as a whole? Should continuing and complex health care be provided for patients
whose conditions are self-induced?
Although it is stylish today for health care professionals to talk about working
with patients as partners in the health care enterprise, patients have reported that
they do not feel they are part of such an arrangement. Instead, they feel like num-
bers "being shuttled about" in the absence of psychological preparation for certain
experiences, such as intensive care units, where the prevalence of electronic moni-
toring equipment is in sharp contrast with the lack of human warmth and compas-
sion. Some patients have felt like "intruders" and they have experienced, from
health professionals, little or no inspiration to make the special effort that is neces-
sary to get well [17].
It is obvious that nurses and physicians share the "commitment not just to indi-
vidual life but to the institution of life" [17]. If they and their professional associa-
tions are concerned solely with professional and territorial questions, their profes-
sions and the members could become and remain insulated from this control role,
with the result that they would "trail happily after illness while ignoring ... [their]
obligation to help humanize society and make it safe and fit for human beings" [17].
This requires not only expertise in professional practice, but also knowledge about
ethics or understanding of ethical systems or moral reasoning and "good moral re-
flexes" [18]. These can be refined through the help in the clarification of ethical val-
ues and issues that is available from colleagues who understand the situations in-
volved. Physicians and nurses who demonstrate what they profess, that is,
participatory membership on a health care team, practice as colleagues - with re-
spect for each other's expertise and contributions, consideration of each other's
points of view in their decision making, and genuine collaboration in the common
goal of the promotion of functional competence in the recipients of health care.
Such practitioners feel no obligation to shoulder the burden of blind obedience to
prescribed procedures and the maintenance of traditional values. Like Socrates,
they believe that "the unexamined life is not worth living." Hence, they assert them-
selves and challenge existing beliefs and practices if what they see in the situations
in which they find themselves, including their own behavior, is not consistent with
the standards of practice for which they stand accountable.
6 Cooperative Health Care Practice
Health care delivery should not be a power struggle - a struggle between diverse
vested interests with shifting alliances, depending on the issue and the disparate in-
terests therein. In a democracy, most people still identify individual rights and free-
dom as extremely important, if not inviolable. However, group efforts and partici-
pation of many people are seen as useful approaches to the solution of common
problems. Public accountability by health care institutions has led more and more
people to question programs and expenditures as they never did before. They are
demanding moral leadership in health care. There is growing recognition that re-
sponsible health care leaders must be sensitive and responsive to the people who
provide the care as well as to those who receive it. Health care workers, including
nurses, are prepared no longer to have little or no input to the nature and shape of
the health care system. They realize that they have knowledge and experience that
suggest directions for health care and they insist on being heard. If their advice is
sound, it will contribute to the optimization of the use of human and physical re-
sources. It has been suggested that if the health care industry is to fulfill its mandate,
the wise manager would be prudent to examine, with his peers and other colleagues,
the goals of his institution in the light of present social needs and current fiscal reali-
ties and to ensure that the services of the institution have relevance for the needs
and aspirations of the citizens of the community. The alternative is organizational
obsolescence [19]. Improvement of the health care system can be done only by the
providers of health services who must work within the resources allocated to them.
They also must work cooperatively with the other disciplines and services involved
to provide a health care system in general and specific services in particular that are
most appropriate for the people to be served in the particular context.
In conclusion, although the essence of human actions lies in the heart and soul
found in them, actions are judged by the difference they make in the world. Effec-
tive nursing practice depends as much on the humanity of the nurse as it does on the
nurse's knowledge and technical skill.
Nurses who recognize and respond to the human needs of patients discover a
rich source of knowledge and understanding. Nurses who respect and collaborate
with colleagues find strength and support. The professional roles of nurses and the
human relationship inherent in them include specific responsibilities, privileges,
and rights.
The nursing profession, as part of its constant pursuit of optimal impact, is keep-
ing nursing's ethical dimension under constant scrutiny. This is part of the challenge
that we, the nurses of the 1980s, have accepted: to subject our own profession to
constructive criticism in order to determine the need to transform the old order into
a new and better one. Such action will not provide solutions for all of the ethical
problems in nursing practice. However, it can stimulate us to continue to strive for
excellence, to apply appropriate ethical concepts to the situations in which we
work, and to be sensitive to the need for thoughtful and sound decision making in
the face of ethical dilemmas.
I believe that ethics and nursing practice in the 1980s can be compatible. How-
ever, they will be compatible only if we, as nurses, make them compatible.
References
1. Flaherty M (1975) Professional obligations with effective rewards. Alberta Association of Regis-
tered Nurses Newsletter, June
2. Aurelius M (1960) The meditations, IV, 12 (translation by George Long). Doubleday, Garden
City, p37
38 M.J.Flaherty
3. Aristotle (1933) The metaphysics Book I, 1, 11-12 (translation by Hugh Tredennick). Heine-
mann, London, p 7
4. Dolan J (1973) Nursing in society - a historical perspective, 13th ed. Saunders, Philadelphia,
p175
5. Hammarskjold D (1966) Markings. Faber and Faber, London, p87
6. College of Nurses of Ontario (1979) Standards of nursing practice: for registered nurses and
registered nursing assistants, revised. College of Nurses of Ontario, Toronto
7. American Nurses' Association (1973) Standards of nursing practice. American Nurses' Associa-
tion, Kansas City
8. Curtin L (1982) The nurse-patient relationship. In: Curtin L, Flaherty M (eds) Nursing ethics:
theories and pragmatics, chapter 8. Brady, Bowie
9. Benoliel JQ (1982) The nurse-family relationship. In: Curtin L, Flaherty MJ (eds) Nursing eth-
ics: theories and pragmatics, chapter 10. Brady, Bowie
10. Flaherty MJ (1982) The nurse-physician relationship. In: Curtin L, Flaherty MJ (eds) Nursing
ethics: theories and pragmatics, chapter 12. Brady, Bowie
11. Flaherty MJ (1982) The nurse-institution relationship. In: Curtin L, Flaherty MJ (eds) Nursing
ethics: theories and pragmatics, chapter 13. Brady, Bowie
12. Curtin L, Flaherty MJ (1982) The nurse-nurse relationship. In: Curtin L, Flaherty MJ (eds)
Nursing ethics: theories and pragmatics, chapter 11. Brady, Bowie
13. Levenstein A (1980) The adversaries. Supervisor Nurse 11 : 47
14. Levenstein A (1980) Dual loyalties. Supervisor Nurse 11: 23
15. College of Nurses of Ontario (1908) Guidelines for ethical behavior in nursing. College of
Nurses of Ontario, Toronto
16. Tiberius RG (1979) Medical ethics \n the next 25 years. Can Faro Phys 25: 76
17. Cousins N (1979) Commentary: medical ethics - is there a broader view? JAMA 241, 25: 2712
18. Tiberius R (1979) Medical ethics in the next 25 years. Can Fam Phys 25: 77
19. Chenoy N (1980) Technology and human choices in health care. Health Man Forum 2: 54
Treatment
Legal Implications of Standards of Nursing Care

K.Scherer
1 Introduction
Witlt the evolution of nursing from the physician's handmaiden role through the
apprenticeship period to full professional status, many changes have occurred.
Fundamental to these changes has been the transformation of the definition of
nursing practice. Once it was subsumed under the definition of medicine; however,
many jurisdictions now have a unique ,definition of nursing practice contained
within legislation. While earlier definitions tended to be task oriented, current defi-
nitions of nursing practice tend to be brC?ad and general. Although supportive of a
more independent practice base, they have necessitated the formalization of stan-
dards of practice in order to describe nursing's accountability and responsibility.
The need to describe what constitutes competent nursing practice is most clearly
perceived when a nurse is accused of negligence or incompetency.
Certainly in common law countries, the expert nurse witness has a long-stand-
ing tradition of providing testimony in cases of negligence and incompetency. Gen-
erally, an expert nurse witness provides a reliable opinion about the standard of
care that can be expected to be provided by a "reasonable and prudent" nurse in
cases of negligence. In cases of incompetency the nurse witness provides an expert
opinion supported by professional credentials about the standard of care provided
by competent practitioners in the same locality. The testimony provided by these ex-
perts traditionally has been viewed as the criterion by which nursing behavior may
be evaluated. However, this tradition of the expert nurse witness has been far from
satisfactory, for it embodies an oral standard of nursing care. As nursing moves
from a dependent, task-oriented base to a more independent, decision-making base,
the replacement of this oral standard, as exemplified in the expert nurse witness, by
formalized standards, is required.
As the professional nursing association in the province of Manitoba, Canada,
the Manitoba Association of Registered Nurses (M. A. R. N.) has a mandate to pro-
tect the public interest by insuring that qualified nurses are licensed and practice
nursing in accordance with professional standards. The revised Registered Nurses
Act of 1980 empowered the M. A. R. N. Board to "develop, establish and maintain
standards for the practice of nursing" [8]. The purpose ot this paper is to describe
the establishment of content validity in the second edition of the M. A. R. N. Stan-
dards of Nursing Care [7] and to explore the legal implications of these standards by
examining alternatives to the expert nurse witness.
40 K. Scherer
2 Materials and Methods
From October 1979 until May 1981, collaborative research was conducted by the
M. A. R N., and the University of Manitoba School of Nursing for the purpose of
revising the M. A. R N. Standards and establishing the content validity of these
standards. While the methodologies have been described in earlier papers [4, 5], I
will briefly summarize these now. The approach to content validation of the
M. A. R N. Standards is a unique achievement in North America and set the basis
for the current development of valid and reliable instruments to measure the stan-
dards.
Measurement theory from the disciplines of education and psychology has spe-
cified content validation procedures. Our application and further refinement of
these procedures resulted in the following methods: First, a review of the nursing
and quality-of-care literature was condu9l:ed. From this review the behavior domain
to be measured in the Standards was identified and the conceptual framework for
the behavior domain and its evaluation was delineated. Next, subject matter experts
were consulted to identify the content sampling of the behavior domain. Finally, the
resulting criteria and standards [1] would serve as the test specifications for future
measurement items by identifying the kinds of topics to be covered.
From the review of the literature, the practice of nursing was conceptualized as
the universe with four behavior domains: research, education, administration, and
clinical nursing or direct nursing care. Direct nursing care was selected as the be-
havior domain for the establishment of standards. From the literature review we
were also able to formulate our conceptual framework which included the nursing
process; Donabedian's [2] model of structure, process, and outcome; and William-
son's [9] outcome framework of diagnostic, therapeutic, and educational out-
comes.
The second method in establishing content validity would be the formulation of
criteria and standards thought to be indicative of the quality of direct nursing care,
within our conceptual framework. The explicit method of developing an objective
list of criteria, against which raters would evaluate care, was selected. Two metho-
dologies for developing explicit criteria have been reported. The first entails using
experts to establish normative standards, while the second entails using practitio-
ners to develop empirical standards. A decision was made to use a blend of the nor-
mative and empirical methods of setting explicit criteria, that is, we would use ex-
perts and practitioners. This blend would provide us with a more solid base for the
establishment of content validity.
Consultation with subject matter experts was the next step in the content valida-
tion procedure. The M.A.RN. Special Committee on Standards was the first ex-
pert group and was composed of 16 members representative of all areas of nursing
in the province. Over a 7-month period, criteria and standards thought to be indica-
tive of the quality of direct nursing care were developed.
Other subject matter experts and practitioners were selected from the sampling
frame of the population of active practicing nurses in Manitoba. The population
was stratified based on the type of employment and four major strata were selected
and operationally defined:
Legal Implications of Standards of Nursing Care 41
1. practitioners involved in direct nursing care,

2. administrators,
3. researchers, and
4. educators.
The sample size of each stratum was determined by proportional random sampling
without replacement. The barriers encountered in identifying and accessing the
populations of educators and researchers and our subsequent decision to identify
these populations in Canada, as well as to sample from the membership list of the
American Nurses Association Council of Nurse Researchers, is reported elsewhere
[4].
A questionnaire was developed in order to elicit opinions about the Standards
from this sample of nurses. In designing the Delphi questionnaire we were mindful
that one of our content validation tasks was to ascertain not only that the Standards
were "desirable" but also that they were "necessary." In order to accomplish this,
three questions were asked.
Question 1. In general, across all types of nursing settings, this item must be present
and/or put into practice in order for good nursing care to be provided. Do you
strongly disagree, moderately disagree, neither agree nor disagree, moderately
agree, or strongly agree?
Question 2 a. This item mayor may not apply in your setting(s), for various reasons.
However, the present standards indicate that each item should apply. Do you
strongly disagree, moderately disagree, neither agree nor disagree, moderately
agree, or strongly agree that this item should apply in your setting?
Question 2 b. At the present time does this item apply in your setting?
Respondents were asked to reply to the three questions in relation to each of the cri-
teria and standards. The questionnaire was pretested by the Standards committee
and 16 nurses representative of the study population.
3 Results
The overall response rate to the questionnaire was 73% and resulted in achievement
of consensus. For the first question, the resulting mean scores on a scale from 1,
"strongly disagree", to 5, "strongly agree", ranged from 3.6 to 4.9. The overall mean
response to the first question was 4.59 and to the second question was 4.5. Having
developed the Standards, we now needed to consider what legal implications they
may have.
42 K. Scherer
4 Discussion
In Manitoba, as in all provinces except Quebec, the legal system is based on English
common law and statute law. Let us first consider the legal implications of the Stan-
dards under statute law. The statute governing the practice of registered nurses in
Manitoba is The Registered Nurses Act [8]. The M. A. R. N. Standards of Nursing
Care could be submitted as a Regulation to The Registered Nurses Act, subject to
approval of the Lieutenant Governor in Council. However, this is a prolonged
procedure and does not permit flexibility in revising the Standards to reflect
changes in practice, and this is not being considered by the M. A. R. N .. Board.
The Manitoba Legislative Assembly has delegated the authority for administer-
ing The Registered Nurses Act to the M.A.R. N. Within the Act, the M.A. R. N. ful-
fills one of the requirements of a profession, that of self-regulation. To accomplish
this the Act provides a two-pronged mechanism in which nurses accused of profes-
sional incompetence to practice are referred to a Complaints Committee in an at-
tempt to informally resolve the complaint. Professional incompetence refers to a
lack of knowledge, skill, or judgment in caring for a patient or disregard for the wel-
fare of a patient [6]. When a complainant does not accept this informal resolution or
it appears that there are grounds for further action, the matter is referred to an inves-
tigation chairman who conducts' a preliminary investigation to determine whether
an inquire should be held by a Discipline Committee. Decisions by the Discipline
Committee may be appealed to the M. A. R. N. Board or the Manitoba Court of
Queen's Bench.
Although in the last 10 years we have had only one formal complaint concerning
a member's professional incompetence, we do not expect this pattern to continue.
What I would like to explore and discuss is the current dilemma which confronts
the M. A. R. N., vis-a-vis the legal implications of the Standards. Prospectively,
M. A. R. N. members accused of professional incompetence could be encouraged to
enter the Standards, or pertinent parts of them, as evidence to defend their conduct.
On the other hand, specific criteria from the Standards could be entered as evidence
by the M. A. R. N. in order to evaluate the member's competence. It is anticipated
that the clarity of the Standards, the consensus achieved in the content validation
procedure, and the widespread utilization of the Standards in practice would enable
members to defend their practice as meeting the Standards. From a legal point of
view, this process poses no problems.
However, from a strategic and political point of view, the use of the Standards
for disciplinary purposes could be very problematic. During the development of the
Standards, membership was informed that the intent of the Standards was to im-
prove the quality of nursing care. Implementation and evaluation of the Standards
in an agency could provide baseline data from which educational programs could
be designed and their effectiveness in improving the quality of nursing care could
be monitored. Because of the intent of the Standards and the membership involve-
ment in their content validation, there has been widespread acceptance and utiliza-
tion of the Standards throughout Manitoba and in agencies in other provinces.
The utilization of the Standards for disciplinary purposes, rather than for educa-
tional purposes, could entirely change that membership acceptance. In other loca-
tions, this is already occurring. You may be aware that recently in the United States
Legal Implications of Standards of Nursing Care 43
in the state of Iowa [3] the nursing association, the hospital association, and the
medical society successfully opposed the minimum standards developed by the Io-
wa Board of Nursing. The Standards were opposed on the basis that they were too
specific, as to invite malpractice suits. While the Iowa Standards were developed
without the type of membership input that went into the M. A R. N. Standards and
also for the sole purpose of disciplining members, what is of concern is the tremen-
dous membership opposition.
Let us now examine the legal implication of the Standards, which relates to
common law. English common law is based on precedents. Through the accumula-
tion of judgments arising from individual cases, a body of law called case law is de-
veloped. It is anticipated that individual parts of the M. A R. N. Standards may be-
come accepted in case law over a considerable number of years. M. A R. N.
members accused of negligence or incompetency in civil proceedings could be en-
couraged to utilize an expert nurse witness and cite pertinent criteria from the
M. A R. N. Standards. Thus testimony would be given by the expert nurse that the
M. A R. N. Standards are actually recognized by a reasonable, competent nurse as
appropriate clinical standards. Should the Court upon examination of the evidence
accept a particular Standard, that portion of the Standards will have been accepted
by the Court and embodied in case law. pnce a particular section of the Standards
has been accepted by the Court, because of the role set by established precedents, it
will be easier to have the same part of the Standard accepted on subsequent occa-
sions without the use of the expert nurse witness. It could also influence the Court
to accept other parts of the Standards in other circumstances.
In conclusion, I have described the establishment of content validity in a second
edition of the M. A R. N. Standards and have explored some of the potential legal
implications of Standards.
Acknowledgements. The assistance of Mr. P. Michael Sinclair, B. A, L. L. D., of the

law firm of Thompson, Dorfman and Sweatman in Winnipeg, Manitoba, and the
M. A R. N. staff is gratefully acknowledged in the preparation of this paper.
The content validation of the M. A R. N. Standards of Nursing Care was sup-
ported by a grant from the Manitoba Association of Registered Nurses Research
Fund. The project to develop valid and reliable instruments to measure the
M. A R. N. Standards is supported by a grant from the National Health Research
and Development Programs, Health and Welfare, Canada (Grant
No.: 6607-1238-46).
References
1. Bloch D (1977) Criteria, standards, norms crucial terms in quality assurance. J Nurs Adm 7 (7):
20-30
2. Donabedian A (1966) Evaluating the quality of medical care. Millbank Mem Fund Q 44, 2:
166-206
3. Protests by nurses prompt Iowa board to revise standards. Am J Nurs 82 (2): 211, 236, 238 (1982)
4. Scherer K, Cameron C, Ramsay J, Vogt C, Farrell P (1981) Methodological considerations in the
construction of national data bases: identification of and access to Canadian nurse educators
and researchers. Paper presented at the International Research Conference, Edinburgh
44 K. Scherer
5. Scherer K, Cameron C, Farrell P, Ramsay J, Vogt C (1982) Content validation of the Manitoba
association of registered nurses standards of nursing care. Paper presented at the National Re-
search Conference, Victoria, B. C.
6. Sklar C (1981) You and the Law: disciplinary action and the nurse. Can Nurse 77 (5): 56-58
7. Standards of nursing care (1981) (2nd edn) Manitoba Association of Registered Nurses, Winni-
peg
8. The registered nurses act Manitoba regulations (1980) Manitoba Association of Registered
Nurses, Winnipeg
9. Williamson JW (1978) Assessing and improving health care outcomes. Ballinger, Cambridge,
MA
Practice and Malpractice
K. M.J. Rea
1 Practice: Duties and Rights and Authority
Each nurse owes her patient a duty of care. That duty is owed by each person to his
neighbor. In English common law, a "neighbor" was described by Lord Atkin in the
1932 case of Donoghue v Stevenson [1] as:
persons who are so closely and directly affected by the act, one ought reasonably
to have them in contemplation as being so affected when one is directing one's
mind to the acts or omissions which are called into question.
That duty of care is relevant to the nurse's practice because it is the foundation upon
which any action in negligence is based. Mter the duty comes the breach of that du-
ty, and from that, the resultant damage ..
What is a nurse's duty of care? Everybody is different. Every nurse has differing
and varying opinions of what level of care she owes to her patients, whether she be
on the ward or elsewhere.
The law on the area of duty of care talks of the "reasonable practitioner" test of
the correct way to do a procedure, the reasonable doctor, hospital, pharmacist, radi-
ographer, architect, barrister. There is a plethora of case law on this area.
Let us first look briefly at the doctor's duty of care. It varies according to:
1. The individual doctor's responsibility in that situation, namely his job description
(houseman, registrar, consultant)
2. The circumstances existing at the time of the accident, for example staff short-
ages, the patient's condition, even the doctor's condition! even!
3. The background of what a reasonable doctor would do in those circumstances,
namely, the objective test supplemented by a subjective test
Now, to see what a nurse's duty of care entails, one would have to apply by analogy
those experiences already gained in litigation against nurses in England (none) and
those court cases including doctors (quite a number), and to see what the judges
considered the standard measure of the duty of care.
There is no time to do that now, so I will pass on to the nurse's differing situa-
tions.
1.1 The Ward Nurse
One might say that the ward nurse is in the enviable position of having everything
she needs to care for her patients at her fingertips. At this juncture, I hasten to add
that I realize that not all wards, either in Great Britain or over the rest of the world,
are adequately equipped for lots of reasons, but mainly financial. However, I would
distinguish the ward situation from the community situation, for example. The ward
46 K. M.J. Rea
nurse will, nevertheless, have her problems. A busy, qualified nurse will be preoc-
cupied with a number of things:
1. Her patients: their hygiene and treatment, intravenous regimes, medication, diet
2. Her documentation: reports, orders
3. The doctors: the ward rounds and noting the results
4. The physiotherapists: to whom they are allocated
5. The other paramedical staff, including the occupational therapists; the chaplain
6. The student nurses: teaching, explaining, guiding, rebuking, watching, allocating,
and so on
7. The relatives: explaining, consoling, exploring
8. The ward: hygiene, cleanliness
The Staff Nurse, then, is a lady or gentleman of many roles. Her duty of care ex-
tends into each of these areas. She must use her theoretical knowledge, learned in
nursing school, and apply that to the practical situation. In this situation, she must
have in mind the theoretical side of her procedure, for example, the drug's names,
both proprietary and original; its side effects and contraindications when she ad-
ministers it.
That would apply to the intravenous infusion, for examples, to check the infu-
sion being put up, with a witness present; to ensure that there is no contraindication
with the previous infusion, such as administering dextrose after blood without
changing the infusion set, because the blood will clot in the infusion line. It would
also apply to intravenous drug administration, for in IV therapy, there is always the
increased risk of error, by virtue of the fact that this direct method of administration
has immediate effect.
Other dangers in this sphere include the calculations of the drugs heparin and
insulin.
Special regard must, I feel, be given to the different types of syringes available in
the world for insulin administration. Some have 20 divisions per milliliter, others
have 10 divisions per milliliter. U-80 insulin will have a strength of 4 units per divi-
sion with the first syringe, but 8 units per division with the second syringe. So it is a
highly dangerous practice simply to presume in this area. I would, therefore, recom-
mend that a nurse get paper and pencil and quickly calculate out how many units
per space and divide her answer into the prescribed dose. This will give her the
number of spaces or divisions to draw up on the syringe. I know it is laborious and
time-consuming but it is safe - and safety is what this is all about. Mistakes can of-
ten be made, but more so under extreme pressure, in these days of staff shortages.
Each hospital nurse has her own area with which to contend, its specialities and
difficulties. For example, the operating room nurse who has a duty to her patient,
the surgeons, the anesthetists and others, including the operating department assis-
tant and, of course, her own colleagues. This is much more a team effort than per-
haps on the wards, for here her duty of care extends to others in that operating thea-
ter.
The accident and emergency nurse has to guard against the unexpected; the
abusive or violent patient. She must be the type of person to act quickly and effi-
ciently and, at the same time, take into account the results of her acts or omission.
The community nurse has quite different problems from the ward or hospital
Practice and Malpractice 47
nurse. By the very nature of her job, fingertip luxuries are not before her. She is
probably the type of nurse who enjoys the challenge of "making do". She owes a
duty of care to her patients not to exceed her own limits. She is alone when she does
her work and must guard against, for example, the temptation of trying to lift a
heavy patient on her own. This could result in injury not only to her patient but also
to herself. So we see here the nurse's duty of care extending to herself. It is clearer
now, I hope, just on what fluctuating sands the duty of care rests. I will add four
more general comments before moving on to malpractice.
1.1.1 The Student Nurse
The reasonable nurse includes also what would be reasonable for a student nurse to
have done. So, for example, the standard hoped for from a first-, second-, or third-
year student nurse, befits only, and no more, a reasonable first-, second-, or third-
year student nurse. This is notwithstani1ing a case called Nettleship v Weston [2],
where it was held that the standard of the duty of care of the learner driver was that
of an ordinary, prudent, and reasonable,driver, with a driving license and quite fully
fledged. I believe that one cannot adequately equate a driver of a motor vehicle with
a nurse. The student nurse does not know many procedures or a great deal of infor-
mation when she is, let us say, a first-year student. The learner driver after just his
first lesson, it is hoped, will have at least the car moving, which is after all the es-
sence of driving.
1.1.2 The Senior Nurse
With regard to sisters, head nurses, nursing officers, directors of nursing services,
district nursing officers, and regional nursing officers: their role is of great impor-
tance. Their duty of care differs from that of the lower eschelons, but it is still vital.
The buck tends to stop elsewhere in these areas if something does go wrong (for ex-
ample, if a negligence action is ensuing). Their liability is that of the overseer, the
person who must certainly satisfy herself that the workforce beneath her is doing its
allocated tasks in a reasonably safe and caring manner. The District Health Author-
ity (DHA) takes the responsibility of the erring nurses for some negligent acts or
omissions. Nevertheless, as stringently as the DHA would investigate the ward
nurse's acts or omissions, so it would also investigate the senior nurse's position to
see if she had adequately protected the patients from that nurse by overseeing those
acts or omissions, whether she had acted correctly in reporting the misfeasance to
her own seniors, and whether she herself could or should have intervened to stop
the negligent act or omission occurring initially.
With increasing technology and documentation all trained nurses are now find-
ing their workload and responsibility increased. And I would say this: it is a legal
maxim but it applies so aptly to the health services around the world: "The greater
the risk, the higher the duty of care."
48 K. M.J. Rea
1.1.3 Documentation
With regard to this, in England, at present, we now have the gradual implementa-
tion of a method of nursing called the nursing process. Some of you may already
know this from your own countries, especially the United States. I believe it is still at
embryo stage in England and there is much discussion still on its legality and use.
The document side of it replaces the old visual display unit, sometimes known by
the proprietary name of Kardex, which all nurses were told in the past was "the le-
gal document". No one really gave much thought, until recently, to this, until sud-
denly we were confronted with a bundle of documents called the nursing process,
and then thought, well how can all that be the legal document? This has yet to be
decided upon, but one problem here is relevant: the duty of care as described under
the "Plan" section. This often results in the nurse having to commit to ink and paper
how long she estimates the pneumonia to resolve or the pressure area to disappear,
to give but two examples of patients' problems. Additionally, the trend in England
is to share this documentation with the patient, which itself has problems to do with
"secrecy". What happens if the patient sees that his pneumonia after 10 days has not
resolved as the nurse expected and wrote down, but instead that it had worsened. Is
the nurse here in breach of her quty of care to the patient in not so "curing" him?
Some would argue that it is so; others, that one could say here that the patient could
be told that no matter what was put down in writing, nothing can guarantee the plan
to work to the day, such is the inconsistent workings of the human body. It is an un-
predictable area. Nevertheless, some litigious patient might take advantage of such
a situation. He would have good ammunition for a claim in negligence. This is the
lower end of the scale, but other hospital-induced complications can be deep vein
thrombosis and pulmonary embolus, for example.
1.1.4 Litigation
I must point out now that the incidence in England, for suing nurses in their own
name, is rare; indeed there are no such reported cases in the law books. Instead the
Authority takes vicarious liability (a form of secondary liability) for the nurse'sac-
tions or omissions, if the nurse is contracted to work for the Authority.
However, it is changing; the British public are now (one could say, at last) be-
coming more educated in their legal rights when they enter hospital. The Carol
Brown case, to name but one highly meritorious claim, puts three midwives in
somewhat dubious limelight. 1 It must be emphasized now that no matter what the
patient feels about his claim against the Authority, there is a danger - small hitherto
- that if the nurse either acts outside the scope of her employment (for example, has
a drink in a public house instead of doing the drug round) and is, in effect, to quote
one of our Law Lords "on a frolic of her own," or has acted in so grossly a negligent
manner as to take her outside the duty of care in which a "reasonable" nurse would
1 The Carol Brown Case was unreported, save for newspaper reports at the time, of the amount
of demages awarded since the case, although litigated briefly in Court, did not reach the stage for
Judgement from the learned Judge. It was settled before that stage
act. then the Authority could either refuse to take vicarious liability for her or ask
her for an indemnity by way of third-party proceedings, when the patient sues the
Authority.
Luckily to date the public may have either
1. failed to recognize the essence of primary as well as vicarious liability or
2. taken the attitude that, even if they did recognize it, the likelihood of suing an in-
dividual nurse is remote because of the British image of the nurse - the adminis-
tering "angel" - and her impecuniosity, or both.
I say this guardedly, for I and my colleagues already begin to sense, day by day,
when we nurse in the true practical sense, the rumbles of complaints, abruptness,
and simple ungratefulness. It is a vicious circle and one which breeds more defense
mechanisms; and Heaven help us if we end up as "defensive" practitioners. This
area could be discussed at great length, bearing in mind comparisons with the
United States and the increasing trend in England towards "privatisation". I will
end this portion by simply advocating, again, with undiscussed reserve, the Swedish
and New Zealand "no fault" system. Again there are certain criticisms of the Acci-
dent Cotnpensation Corporation scheme of New Zealand which are beginning to
be manifested, I believe. '
2 Malpractice
Malpractice is really the breach of the duty of care I have outlined earlier, in simple
terms, with the resultant damage to the patient/victim.
1. I have just a few examples for you: A newly qualified doctor prescribed 5 units of
insulin to be injected intramuscularly into a patient with dangerously high potassi-
um levels and a provisional diagnosis of malaria with hepatorenal failure. The
nurse administered the insulin in a large syringe. She had given 5 ml of insulin in-
stead of 5 units, 40 times the normal dose. The patient later died.
2. Ether was used in skin preparation in an aortoiliac reconstruction on a patient
with intermittent claudication. Later, a femoral arteriotomy was performed during
which the surgeon called for heparinized saline to inject into both common iliac ar-
teries. He was handed a syringe with an attached cannula, by the nurse. The cannu-
la stopped working and was drawn out. The plastic had dissolved and one artery
was eroded. Efforts to revive circulation in the leg failed and at a later date the leg
was amputated. The nurse had negligently used the same gallipot for the heparin-
ized saline as she had earlier used for the ether, leaving residual ether in the gallipot,
and allowing its introduction through the cannula into the artery. The relevant
Health Authority eventually settled the claim on behalf of the nurse concerned.
3. The Carol Brown case. An epidural anesthetic was administered to Mrs. Carol
Brown to aid in the labor stages of the delivery of her son. That was several years
ago. Today she is paralyzed below the waist; has restricted arm movements; and
persistent pain in the lower chest, arms, and feet, due to negligent administration
and/or lack of administration of an additional dose of the epidural. In January
50 K.M.J.Rea
1982, Carol Brown was awarded 414,563 after Mr. Justice Taiyler found the Area
Health Authority (AHA) vicariously liable for three midwives present at the rele-
vant times. The AHA took liability in two ways:
- for the midwifery sister for inadequate supervision of the two staff midwives, and
- for the two staff midwives (one of whom was an agency nurse) who failed to "top
up" the epidural at the proper time, or, alternatively who inadequately topped it
up. Neither had the necessary Certificate of Competence to do such a procedure.
Now the Royal College of Midwives and the Central Midwifery Board are to issue
a joint statement clarifying the role of midwives called to administer such an injec-
tion. A midwife may now only top up or administer the epidural if she has been
properly trained or instructed, but the responsibility of ensuring she is competent
rests with the local employing authority.
Rather like shutting the stable door after the horse has bolted, one might be
tempted to say. Alternatively, better late than never. Malpractice is like a great dam
ready to burst. One keeps "patching up" the parts that crack and leak, and it stays
moderately intact, but that cannot last forever. One day the dam might burst and
then we will be flooded with claims. That is why it is better to prevent rather than
cure.
3 The Emergency Situation
There are various situations where emergency treatment will be required: in the
emergency room, the operating room, the intensive care units, the coronary care
unit, on the wards, in the community, in midwifery, and, of course, on the highways
and byeways. Each nurse (as I have already discussed in this paper) has her own du-
ty of care within her own speciality or sphere.
It will, nevertheless, be recognized that in an emergency situation the nurse is
working under more pressure and stress than usual. In juxtaposition to this, one has
to remember the higher the risk, the greater the duty of care.
In the resuscitation situation the nurse must take extra care with the drugs. She
and the doctor will be using drugs as called out by the doctor, as passed to him to
use by the nurse, which might not be noted, and might be forgotten later when the
situation is calmer. Use of another nurse to note names, dosages, routes, and the
doctor's name would be wise, if there is a nurse to spare on the ward. This informa-
tion can then later be prescribed by the doctor and signed off by the nurse in the
usual way, with the records made in the nursing notes, if that is the practice.
Care in the use of the defibrillator is important. The obvious dangers here are
electric shock, burns, death from wrong or incompetent use of such a machine. The
doctor is the only person, in England, who is permitted to use it on the patient, al-
though the nurse is permitted, and often required, to check it. The electrocardio-
gram is also another area where care must be used, for if the nurse holds herself out
to do such a procedure and it is done incorrectly, it could lead to unnecessary alarm
and timewasting, for the doctor will have to do it again. For this reason, many
nurses refuse to do an ECG for the doctor. This and other "requests" are examples
where the duty of the nurse is inadvertently widened because she is either unwilling
to acknowledge her own limits (there is "kudos" in doing an ECG for a doctor) or is
too confident of her abilities. Needless to say, this would hopefully not apply to a
fully trained coronary care nurse.
The casualty nurse must guard against improper information being conveyed to
patients, either over the counter or on the telephone. Here she is far more vulnerable
than her counterparts for she is on the direct "firing line" of the public (excuse the
phraseology!). Diagnoses over the telephone must be avoided no matter how per-
sistent the potential patient is. No doctor worth his salt would do so, and it is not,
therefore, for the nurse to do such a radical thing, tempting though it may be.
I will conclude this section by saying that these examples are by no means an ex-
haustive list of situations in which to take added care. That would take a long time
to postulate. I leave these to the individual's common sense to cope with, for one
can be too "spoon fed".
4 Legal Proceedings: Nurses in Court
There are four main areas in the United Kingdom in which a nurse may be required
to attend a court of law:
1. As a witness in the coroner's court
2. As an expert witness
3. As a witness of fact
4. As a defendant in a civil action
As a witness in the coroner's court the nurse gives her evidence relating to her
words or actions at the relevant time. She will be guided through this by her own
lawyer and often the coroner, an experienced doctor and lawyer. Then she will be
cross-examined by the deceased's lawyer if her actions leave any room for doubt.
Re-examination takes place to clarify any points in cross-examination. Everybody
in the coroner's court is there to see the truth elucidated in the best interests of the
deceased person. Sometimes it is easy to mistake the family's interests as being par-
amount, with regard to potential legal claims and possible damage, but in theory
this should not be so.
As an expert witness, the more technological nurses become, the more judge's
deem them to be experts. When giving expert evidence in court, she must be careful
not to give her personal, nonprofessional opinion, nor an opinion based on hypoth-
esis. As a factual witness, the help a nurse in this instance can give would include
reading out an undisputed fact of the nursing record in order for the court to obtain
a chronological sequence of events, on the day in question, for example. Also if she
is the owner of an agency she might give evidence as to cost with regard to the future
care, in monetary terms, of an accident victim who was, as a result, severely handi-
capped and needed a private nurse.
As a defendant in a civil action. This would be an unfortunate court appearance,
but one which should not necessarily fill the nurse's heart with fear. Provided she re-
mains clear, concise, and answers in a loud voice, looking at the judge, she should
find that he will regard her with the professionalism which she deserves (whether
that be a great deal or a small amount). No matter how negligent the nurse has been,
if she tells the truth initially when her own lawyer is examining her, she will find
52 K.M.J.Rea
cross-examination much less onerous, for a good lawyer will try to preempt any
awkward areas before cross-examination. Sober dress is recommended. So have no
fear. Everybody in court is there to help, not to hinder, and nurses are highly re-
spected as a profession by judges.
5 Professional Secrecy
Finally I come to the last topic in my paper. How desirable is secrecy in our profes-
sion? Does it have a place? One has to balance the rights of the patient to know and
see documentation written about him, against the possible breach of confidentiality
of what could often be sensitive and embarrassing areas, and comments about the
patients diagnosis and prognosis. This type of breach could occur to the patient di-
rectly or to somebody else who has obtained certain nursing and medical records.
Often patients, by implication, do not wish to know their diagnosis if, for example,
that diagnosis is cancer. The nurse must judge as she sees it fits the individual cir-
cumstances.
This secrecy can be encroached upon. It is in the areas of release of documents
to the patient with litigation in mind that the English law has manifested the current
trend of thinking here. As a result of a 1978 case [3], the government passed the Su-
preme Court Act 1981, codifying the law, until then. It took effect on 1 January
1982. Its effect was to make available to the patient/victim/applicant and/or his le-
gal advisor and/or his medical advisor (or other professional advisor), before or
during legal proceedings, if the court so orders, such relevant documentation as the
court deems necessary and reasonable. The applicant has to be a potential litigant
in subsequent proceedings. The change in the law here is that now, if ordered, the
Authority and/or the doctors have to release such documents to the patient, who
can read them himself. Hitherto, the documents were habitually released to the le-
gal advisors and occasionally to the medical advisors, but very rarely could the pat-
ient read them.
What untold damage can it now do to the patient to see in cold print such things
written about him as "this discontented elderly man ..." (in the doctors' notes) or
"patient was extremely uncooperative and obstructive today. Recommended for se-
dation" (in the nursing notes)? We speak of "professional secrecy" and many corre-
late that with the word "whitewash". That is not so. The secrecy (and I prefer the
word confidentiality) is not only to safeguard doctors and nurses against defensive
practice, but also to safeguard the patients against themselves, and that cannot be
emphasized too greatly. To some extent some secrecy must be preserved for these
reasons and also to prevent the "fishing" expeditions in which the over-litigious pat-
ient could indulge if he finds himself without a cause of action, but wants to find
one, from his notes.
The Medical Protection Society of Great Britain [5] has issued advice in a leaflet
about confidentiality, which recommends the doctor and Health Authority to en-
courage voluntary disclosure of such information. This means that the applicant
must swear an affidavit giving reasons why he wants the requested documents. If ei-
ther he is unwilling to swear the affidavit, or the Authority feels that the reasons are
inadequate, then the applicant is advised to obtain a court order for disclosure of
the documents. Thus, initially at least, friendly helpful moves may be made by both
sides, for nobody wants to deprive the genuine hospital accident victim of his com-
pensation.
So it seems that we must take a leaf out of our colleagues' (the doctors) books
and attempt to participate in voluntary disclosure at the Regional Health Authority
level, with proper legal advice. Very recently, it has been held in quite clear terms
that nurse's reports are, sooner or later, if relevant and reasonable and if the court so
orders, bound to be disclosed to the patient [4].
Again, is the patient's right of confidentiality going to be eroded if the nurse
openly uses the nursing process documentation in the ward with the patient? There
are dangers of overexposure of this document: a nosy neighbor or a curious visitor
or relative may read it if it is left at the end of the bed, as they indeed are in some
English hospitals. The balance has yet to be resolved either in the wards or in the
district, but with foreknowledge of the dangers, one hopes they will be avoided in
practice.
I leave you with some thoughts. When we raise an arm to start treatment on a
patient our duty of care begins.
Ask yourself:
1. What is my duty of care to the patient?
2. How much risk is there to the patient?
3. And then add the cream to the milk - the higher the risk, the greater the duty of
care. The greater the duty of care, the greater the care to be actually taken in prac-
tice; but at the same time let us not become "defensive" nurses.
Florence Nightingale, in whose training school I had the honor to be trained, start-
ed it all; do not finish it by dripping the burning oil from your lamps on to your pat-
ients.
References
1. Donoghue v Stevenson (1932) Appeal Cases, p562

2. Nettleship v Weston (1971), 2 Queen's Bench Division, p691
3. McIvor and Another v Southern Health Services Board (1978), House of Lords 2, All England
Law Report, p625
4. Campbell v Taneside Metropolitan Borough Council (1982) The Times, 30 April 1982
5. Medical Protection Society (1980) Consent, confidentiality Disclosure of Medical Records. The
Medical Protection Society, London
Legal Aspects of Surgery in England
E.Dixon
From Queen to commoner, we must all render obedience to the law. "Justice, Sir,"
said Daniel Webster, "is the great interest of man on earth." Law is something that
changes and can be altered if justice demands it. English law is partly written and
partly unwritten. Written law is statute law and it consists of acts of parliament. A
good deal of English law rests on custom, or what has been done before, and is
called common law.
Nurses must not only live according to the law of the land but they must also
practice within the legal confines of their professional qualifications. They are re-
sponsible for their professional practice to the General Nursing Council, which will
eventually be replaced by the newly established statutory. bodies of the Nurses,
Midwives, and Health Visitors Act.
The law protects the rights of patients, and in the generality of cases, surgery
cannot be performed without the patient's consent. Failure to obtain this consent
will usually amount to actionable trespass to the person for which the surgeon and
those helping him may be held personally responsible.
Consent can be oral, written, or implied and all are of equal value in law, al-
though written consent has the advantage of providing a permanent record. To be
valid, consent must be given freely and given only after the proposed operation has
been explained to the patient by the surgeon.
The law courts are the headquarters for the administration of justice in England.
Patients are due what is termed "a duty of care" and if they have reason to believe
that there has been negligence in the delivery of this care, they may well resort to liti-
gation. Although alarmist publicity of alleged unethical or criminal activity by a few
doctors or nurses is welcomed by some sections of the press, professional integrity
and high ethical standards are still the rule rather than the exception.
For elective surgery on children from birth to 16 years, the parents' or guardians'
consent is required. Young people between 16 and 18 years can give consent for
medically necessary surgery.
The consent of a spouse is not a legal requirement for a medically necessary op-
eration (for example, a hysterectomy) but as a matter of good practice, it is consid-
ered a wise precaution to obtain it.
In the case of the mentally handicapped patient, the medical officer will decide
if the patient is capable of making a decision; otherwise, permission is sought from
a relative or the medical officer will decide.
In all cases requiring emergency treatment, the surgeon will operate as soon as
possible, whether or not consent is given or available. There is no rule of law which
prevents a patient electing to go to his own death, but it is not to be expected that a
court would readily find against a surgeon who, in a case where prompt action was
required, had taken a course approved by a substantial body of medical opinion. In
the case of a child, it is the surgeon's duty to do all he can to save the child's life, and
if he fails in that duty, he might be charged with manslaughter. By providing neces-
Legal Aspects of Surgery in England 55
sary treatment, he is doing no more than is the duty of the parents, and he may, if
necessary, apply to have the child made a ward of court.
The objection of an adult to elective surgery on religious or other grounds will
always be respected. The same principle applies in the case of children but the sur-
geon has a duty to explain to patients the possible consequences of this action.
Two important booklets are published jointly by The Medical Defence Union
and The Royal College of Nursing, recommending a code of practice to be followed
to prevent mishaps occurring during surgery. These documents outline procedures
which should ensure that the wrong operation is not performed and also that swabs,
needles, or instruments are not left in the wound.
The operating room nurse carries-out a preliminary count, which is repeated be-
fore the incision is closed, and again at the end of the operation.
The count is recorded and retained in the patient's notes.
The booklets are recommendations - not laws - but failure to comply with them
constitutes negligence, which will be acceptable as evidence in a court of law.
Current legislation makes it mandatory for hospital authorities to ensure that
the operating room provides conditions. of optimum safety for both patients and
staff. Some of the precautions taken are as follows.
All floors have antistatic properties and movable equipment is fitted with anti-
static wheels. '
Ventilation and humidity has to conform with Department of Health standards.
All electrosurgical equipment is insulated.
A strict Code of Practice ensures that staff are protected from radioactive sub-
stances.
For every surgical procedure, a strict count is carried out.
Regular checks by health and safety officers ensure that potential hazards are
identified and corrected.
Regular educational programs ensure that staff are conversant with develop-
ments in technology and equipment.
The Hospital Authority and the unions will provide legal advice and guidance
for staff involved in legal proceedings.
The Abortion Act 1967 allow nurses to refuse to participate in procedures which
terminate life. Nurse's objections may be based on religious, moral or ethical be-
liefs, but the Act also states "there remains a duty to participate in treatment which
is necessary to save the life or to prevent grave permanent injury to the physical or
mental health of a pregnant woman."
The Health and Safety at Work Act 1974 states "It shall be the duty of every em-
ployer to ensure so far as is reasonably practicable, the health, safety and welfare of
all his employees." Failure to comply with this constitutes negligence. A large num-
ber of scalpel blades and needles are used in the operating room daily. They consti-
tute a continual hazard to staff but when a safe method of disposal is used there is a
decrease in occupational illness and a reduction in the amount of money paid in
compensation to staff due to accidents.
British justice stands high in the esteem of the world, and the law protects con-
tracts and agreements made between patients and the professionals who care for
them.
Legal and Moral Rights of Mentally III People:
A Critical Argument
R. A. Schrock
One debate which engages a number of nurses, and to a larger extent other health
care workers, voluntary organizations, and patients, is concerned with the "rights of
patients," and predominantly with the rights of mentally ill and mentally handi-
capped people.
Much of the debate, however, is conducted on hand of concrete examples which
are meant to illustrate the breaches of such rights in particular and individual in-
stances. Without suggesting that such examples of instances of deprivation or ill
treatment are invalid or inappropriate, it is nonetheless rare that any attempt is
made to examine and to define the nature of such rights in a caring, professional re-
lationship.
1 Nature of Human Rights
The conception of human rights in a context which must imply a particular view of
man and society is embedded in the rise of individualism and in the development of
social contract theories in the seventeenth and eighteenth centuries, which held as
their most fundamental and common tenet the principle "that the basis and end of
government (is) the security, the happiness, the rights of the individual" [1].
The ensuing declarations which expressed some human rights as ideals or de-
mands served obvious political purposes. But while these various conceptions of
human rights were purposefully applied to political issues, they had originated in
religious conceptions, conflicts, and martyrdoms of earlier times. The eighteenth
century with its doctrines of the rights of man invited a new argument, which for the
first time based its reasoning on philosophical analysis rather than on religious con-
victions. Closely linked to the notion of natural rights, which belongs to the realm of
moral discourse, the whole idea of human rights is essentially a moral proposal.
The doctrine of human rights is a proposal concerning the morally appropriate way of treating
men and organizing society. Like all such proposals that gain force and command respect, it is a
complex proposal, attempting to present a systematic view of man and society, taking up asso-
ciated empirical material, relating and ordering moral preferences [1].
I will therefore argue that a discussion of patients' rights should be part of profes-
sional ethics in its proper sense, that is, prescriptions relating to patients' rights
should be examined in such a way that the nature of the moral judgment required
by the nurse in deciding on the "right" nursing action becomes clear and explicit.
With the emergence of patients' rights into the consciousness of nurses and other
health care workers and of patients themselves, it has become obvious that the mor-
al proposals which are articulated in the declarations of such rights, which can read-
ily be found in the North American nursing literature, are not necessarily realized in
Legal and Moral Rights of Mentally 1lI People: A Critical Argument 57
action. It may be pertinent to note that no such declaration has been fully repro-
duced and discussed in the British nursing literature.
The original idea of human rights, which dermed certain areas of human con-
duct and affairs to be immune from government interference, also embodied the
notion that the people could use justified force against the government if their rights
were not protected by governmental action [2].
One important feature of both legal and moral rights, it seems, is their connec-
tion with coercive power.
John Stuart Mill [3] declared it an injustice to take or withhold from any person
"that to which he has a moral right." He believed that
"When we call anything a person's right, we mean that he has a valid claim on society to protect
him in the possession of it, either by the force of law, or by that of education and opinion."
But not all human rights enjoy the protection of legal enforcement or the force of
public opinion. Nevertheless, there appears to be a conviction among British psy-
chiatric nurses and other workers in the. mental health field that the protection of
the rights of mental patients lies primarily in the hands of the law.
2 Legalistic Conception of Human Rigbts
A scrutiny of British standard nursing textbooks will confirm the impression that
nurses hold a very legalistic concept of the nature of patients' rights. The only refer-
ence to patients' rights occurs in sections devoted to legal aspects of psychiatric
care. The legal aspects, at any rate, are emphasized in theory, if not always in prac-
tice. The Mental Health Acts, which are the relevant acts of parliament, instruct
nurses in the legal provisions concerning the detention of patients in institutions
against their will, treatment without the patient's consent, care of property, guard-
ianship, and the limited protection of the law against assault and invasions of priva-
cy.
Furthermore, most of this instruction is secondhand, that is, few nurses study
and discuss the actual legislative documents but refer to summaries and abstracts
based on someone else's selection from the relevant acts. There seem to be few op-
portunities for nurses to consider the principles on which that legislation is based.
Lacking an understanding of the essential nature of the societal processes embod-
ied in law, they also lack a basis for defining their own responsibilities in relation to
such laws.
In the comparative absence of goal-orientated nursing based on a methodical
assessment of individual patient needs, nurses lack a concrete formulation to help
them translate legislative prescriptions into effective practice. This apparent ineffec-
tiveness in dealing with the nursing problems presented in reality, as when a patient
insists on leaving hospital who is not clearly certified and so not liable to automatic
detention, causes nurses to demand more and better laws.
My thesis is that patients' rights are only partially protected by legal enactments
and will ever be so, even if nurses become more proficient in implementing such
laws in practice.
58 R. A. Schrock
3 Relationship Between Legal and Moral Rights
The rights of mentally ill people must be seen in the context of the rights other adult
members of their society enjoy, which are developed from and based on a moral
consensus. Mutually agreed and customary expectations of what is right and what is
wrong in human conduct inform and regulate all our relationships between one per-
son and another; between groups of people, such as parents and children or teach-
ers and students; and between individuals and formal social institutions, such as the
.church or the government. Not all the rights which an adult exercises and which she
expects will be respected by others are guaranteed to her by law, or if they are, some
can only be enforced if the breach of the law is obvious, substantial, and often ex-
treme. Some examples will illustrate this point clearly.
As a friend I have the right to expect that my friend is loyal to me, does not tell
tales behind my back, keeps his promises, and goes out of his way to help me. If he
fails to do any or all of these things, I can hardly invoke the law, but I can protect
my rights as a friend by a moral sanction, that is, by showing disapproval, or by even
ending the relationship.
As a customer I have the right to expect that I am not cheated and that the goods
I buy are in a usable condition. If I am shortchanged, I may apply a moral sanction
by withdrawing my custom and by causing my friends to do likewise, or I may em-
barrass the shopkeeper by loudly complaining in the shop in the presence of other
customers. If I consider that I have suffered serious harm or considerable inconve-
nience, I may take my complaint to an arbitration body or a tribunal, or perhaps
even to court; that is, I may cause legal sanctions to be applied to the dishonest
shopkeeper.
In some instances, I would have no choice but to rely on legal protection of my
rights, if, for example, I were arrested wrongfully.
The common and criminal law of the country protects certain moral rights of the
people. Legal rights are selected moral rights. Offenses against our rights which
cause serious harm or injury to the individual, which are common, or which serious-
ly threaten social cohesion are legally sanctioned. But the law cannot protect all our
rights. To be legally enforceable, the potential breach of the law must be obvious, re-
cognizable, even quantifiable, it generally must be public so that the complaint can
be substantiated, and often it must be extreme.
4 Moral Offenses Against Mentally III People
From the evidence of many inquiries into medical and nursing practices in mental
hospitals over recent years, there appear to have been fewer breaches of the law
(though it may have been administered inefficiently) than moral offenses against
the rights of mentally ill people, their relatives and friends, and staff who attempted
to restore these rights.
These offenses included the right to adequate and stimulating occupation, the
right to generally accepted standards in the variety of food and in serving it in a
manner consistent with adult expectations, the right to drink when thirsty and not
be denied essential fluid intake, the right to be dressed in a manner consistent with
Legal and Moral Rights of Mentally III People: A Critical Argument 59
dignity and respect for people's customary expectations, and the right to be protect-
ed from exploitation by people who hold power over the smallest details of life.
As recently as 1976, an inquiry found widespread offenses of this nature in a
particular hospital [4]. It highlighted the not uncommon practices of refusing pat-
ients their day clothes for long periods of time (in one instance a patient was kept in
pyjamas and dressing gown for over 4 years), and of serious overmedication (often
as a punitive measure after the patient had proved difficult or disturbing to the
staff).
It found that electroconvulsive therapy was forced on patients who clearly ob-
jected to this form of treatment, and there was deliberate humiliation of patients by
leaving them in soiled and wet clothes or beds.
Teasing to the point of irritation and anger appeared to be common, and fre-
quent slaps on the face, cuffing and other indignities were not unusual. The report
of this inquiry points out in many places that the right of the patients to respect and
dignity was neither recognized nor consequently protected.
The fact that most ofthese moral infringements have been observed in long-stay
wards of psychiatric hospitals and in mental deficiency care settings may reinforce
the point made earlier that an important feature of both legal and moral rights is
their connection with coercive power. These patients are the least powerful and
have little contact with those who could exert power on their behalf. These patients
are hardly able to employ moral sanctions against any transgressor, partly for lack
of social skill, and partly for the real possibility of retaliation by the more powerful.
Reports of inquiry by and large avoid blaming individuals and focus on criticisms
of a system which fails to protect its most helpless members. Although there is little
doubt that members of staff become as much victims of an inefficient and morally
ambiguous system, there is a great danger in negating any individual or personal
blame. Degrading and indifferent actions are carried out by individuals and not by
abstract constructs called systems.
5 Moral Protection of Patients' Rights
It may have become clear that many of the moral offenses against mentally ill peo-
ple are of a nature which does not make them amenable to legal sanctions. They are
rarely obvious but often develop insidiously. From calling patients by stereotyped
and stigmatizing names like "schizo," "psycho," or "junkie," there is a gradual but
invidious development that leads to a whole range of derogatory and diminishing
responses and to the kind of moral offenses that I have discussed. In often stressful
situations, the incident may not even be recognized and far less can such occur-
rences be easily quantified. Most transgressions are certainly not public and are dif-
ficult to substantiate, even if they were of a nature that could make them sanction-
able by law.
A moral consensus that accepts that patients generally are told far less than the
truth, that they may be deceived "for their own good," that promises may be made
to restore control which the nurse has no means of keeping, that a patient's physical
and emotional privacy is invaded without any compunction in the furtherance of
"therapeutic" approaches, and that loyalty to colleagues outweighs almost all other
60 R. A. Schrock
moral obligations provides the climate in which moral offenses against patients be-
come inevitable.
The conclusion that the rights of mentally ill people are primarily upheld by the
conscience of individuals and by the moral consensus of those who understand the
nature of patients' rights and are determined to use their power to enforce them is
inescapable.
The declarations of the patients' rights and their formal adoption by a profes-
sional group are seen by many as a first important step. It may be a sad admission
that many nurses and other health care workers may not be able to articulate un-
aided the moral principles which should govern their relationships with patients.
Jenny [5], an American writer, declares firmly that they need to be brought to the
provider's attention, and although Annas [6] expresses the hope that following a pe-
riod of education, "doctors and nurses will begin to afford patients their rights as a
matter of course," he still feels that the patient at present needs an "advocate" who
can represent his interests, who is only accountable to the patient, and who also has
the power to enforce the realization of his rights. _
Many writers identified various advocacy models such as patient representative,
C9unselor, lay therapist, information provider, health care humanist (sic), watchdog,
educator, spokesman, catalyst, and ombudsman. But these proposals remained
quite vague and nebulous.
There are many perfectly obvious reasons why this role cannot be "split off'
from other caring roles, the most important being that in fact any caring role be-
comes impossible when the patient needs to be "protecteo" against those to whom
he must surrender himself in all his vulnerability.
It is only in each nurse's conscience, in the willingness to accept personal re-
sponsibility, in acting courageously on behalf of the patient, in being committed to
the patient's interest that the moral and legal rights of each patient can be upheld.
References
1. Kamenka E, Tay AE (eds) (1978) Human rights. Arnold, London

2. Popkin RH, Stroll A, Kelly AV (1956) Philosophy made simple. Allen, London
3. Mill JS (1962) Utilitarianism (edited by Mary Warnock). Collins/Fontana, London
4. Report of Committee of Enquiry, St. Augustine's Hospital, Chartham, Canterbury (1976) South
East Thames Regional Health Authority
5. Jenny J (1979) Patient advocacy - another role for nursing? Int Nurs Rev 26: 176
6. Annas OJ (1975) The rights of hospital patients. The American Civil Liberties Union, New York
Involuntary Sterilization of the Mentally Retarded:
Curtailing Procreation Rights of Persons
with Diminished Capability to Claim Rights
S.T.Fry
1 Introduction
Early in 1979, a United States couple in the state of Maryland sought a court order
to sterilize by hysterectomy their brain-damaged, 11-year-old girl. Within the con-
text of the present laws in the state of Maryland, the court ruled that it had no power
to order this procedure unless the procedure was for therapeutic reasons. The court
even went on to state that if the legislature had wanted the court to have the authori-
ty to order nontherapeutic sterilizations, it "would have enacted an appropriate sta-
tute as have twenty-seven (27) other states in this country" [1]. Following this ruling,
a group of Maryland parents joined together to lobby for a state law that would al-
low them to have their retarded children sterilized [2]. Their efforts resulted in sever-
al bills placed before Maryland legislators in 1981 and 1982 [3, 4]. Yet, to date, none
of these bills has been made into law.
The concern in writing the Maryland bills to allow involuntary sterilization of
mentally retarded persons is to ensure that the rights of the individual are adequate-
ly protected through procedural safeguards. This concern is appropriate consider-
ing the sterilization abuses of many retarded persons throughout United States his-
tory. From the notorious 1927 United States Supreme Court decision upholding a
state of Virginia statute to allow the sterilization of 18-year-old Carrie Buck [5] to a
recent decision allowing sterilization of a 19-year-old woman with Down's syn-
drome [6, 7], the United States courts have played a major role in involuntary sterili-
zation decisions. While many of these decisions have, indeed, sought to protect the
rights of the retarded, other decisions have allowed sterilization for morally ques-
tionable reasons [8, 9]. The major problem facing many state legislators, therefore,
is the language of a statute allowing involuntary sterilization which cannot be
interpreted by the courts in such a way that sterilization abuse can occur. At issue
is the moral justification for involuntary sterilization procedures involving the
mentally retarded and the legal language by which both substantive and procedural
due processes are satisfied. During the past year, I have explored the various
components of this process and justifications offered by the courts in recent
decisions regarding sterilization of the mentally retarded. I have found that most
justifications offered to date have not been sufficient, on ethical grounds, to autho-
rize coercive intervention with liberty in the form of sterilization of mentally re-
tarded persons.
In the literature supporting coercive interventions, in general, two justifying
principles are frequently cited: the harm principle and the paternalistic principle.
The harm principle justifies coercive interference with a person's liberty when there
exists supportable grounds for believing that an individual or group of individuals
62 S.T.Fry
has been or will be physically or mentally harmed [10]. The1 paternalistic principle
justifies coercive intervention with a person's liberty in order to benefit or to prevent
harm to that person [12]. Court decisions in the United States have displayed a curi-
ous mixture and inconsistent application of these two principles as justifying rea-
sons for limiting procreative rights. Thus, the first part of this paper explores the
background of court decisions abridging the right of mentally retarded persons to
procreate; the second part examines the use of the paternalistic and harm principles
as justifying principles for involuntary sterilization of the mentally retarded.
It is the thesis of this presentation that in the case of profoundly, severely, and
some moderately retarded persons, involuntary sterilization is justified by the harm
principle, which can be demonstrated to be morally sufficient for coercive interven-
tions. In the case of mildly retarded persons, however, involuntary sterilization re-
quires an application of the paternalistic principle, which can be demonstrated to
be never morally justified on independent grounds as well as in the particular case
of involuntary sterilization of the mildly retarded. Thus involuntary sterilization of
mentally retarded persons is only morally justified in the case of profoundly, severe-
ly, and some moderately retarded individuals.
2 State Authority to Allow Involuntary Sterilization
In the United States, the fundamental right to procreate lies within the liberty inter-
ests protected by the Fourteenth Amendment of the Constitution [13]. The right to
procreate is regarded as fundamental because it is necessary to the very existence
and survival of the human race. As has been pointed out by the courts, curtailment
of this right by the state forever deprives a person of a basic liberty [14]. Thus, there
must be powerful interests on the part of the state in seeking to curtail this right in
any person, including the mentally retarded.
In the past, the state has intervened in this right either on the basis of its police
power authorities or under its authority as parens patriae [15, 16].
2.1 Police Power Authority
In acting on the basis of its police power authority, the state acts to promote the
health, welfare, and safety of the public and not for the benefit of any individual.
Yet the state's power to curtail a fundamental right is limited by the due process and
equal protection clauses of the Fourteenth Amendment. The state must show that
its interest is compelling, that no less drastic means can accomplish the goal sought
by the state, and no group of persons will be discriminated against by the statute un-
der consideration. At the present time, interference by the state under its police
power authority is limited where sterilization of the mentally retarded is concerned.
The state has, however, acted on this authority in years past with devastating results
[17, 15,9].
1 The hann principle is usually considered to justify coercive interference with a person's liberty in
order to protect a person from acting in such a way that he hanns others [11]. Beauchamp [10] has,
however, embellished Mill's principle ofhann to include the notion of unknown hanns to the self
Involuntary Sterilization of the Mentally Retarded 63
2.2 Parens Patriae Authority
When intervening in liberty on the basis of its parens patriae authority, the state acts
to promote the best interests of the individual affected. It does this by acting as a
guardian would to individuals unable to care for themselves and is motivated, at
least in part, by the benevolent purpose of securing the welfare of the incompetent
[18]. The state acts so as to protect the incompetent from coercive interventions,
since they are, by reason of incompetency, unable to question or challenge the inter-
vention. Yet the state must at the same time "choose" for the incompetent (as he
would choose) because the status of incompetency prevents conscious exercise of
choice. Because of this difficulty it is claimed by some that parens patriae is not an
adequate method for authorizing the sterilization of incompetent individuals. Pa-
rens patriae powers are so broad that they may lead to inconsistent decisions [18,
p 330]. In addition, the doctrine may not provide the procedural safeguards neces-
sary to insure an individual's constitutional protection. There is an additional prob-
lem created by the doctrine of parens patriae in that courts may not correctly
"choose" for the incompetent and courts may inadvertantly open the door for po-
tential abuse by its authority. '
My own analysis of court decisions reveals that courts have interpreted deci-
sions made under the various authorities - police power and parens patriae - differ-
ently. There appears to be an inconsistent application of these authorities from case
to case and from state to state. In fact, the latest trend in the courts seems to be that
courts themselves make involuntary sterilization decisions on the basis of the in-
competent's best interests, instead of allowing parents or a court-appointed guard-
ian to make these decisions. This is very evident in the court proceedings concern-
ing Lee Ann Grady, a 19-year-old woman with Down's syndrome [6]. The court
made its decision
... to further the same interests she might pursue had she the ability to decide her-
self. We believe that having the choice made in her behalf produces a more just
and compassionate result than leaving Lee Ann with no way to exercising a con-
stitutional right. Our Court should accept the responsibility of providing her with
a choice to compensate for her inability to exercise personally an important con-
stitutional right [6].
This latest decision is one of three approaches that are now possible in involuntary
sterilization authorizations. As pointed out by Annas, the first or majority approach
"is for courts in states that have no specific statutes authorizing sterilization simply
to declare that it cannot be done on individuals who cannot personally consent to
it" [7]. This approach has been suggested for the state of South Dakota [19]. It is also
the approach taken by Maryland in deciding the 1979 petition [1].
A second approach is to adopt a Quinlan-type decision by "defining the test to
be applied in making a decision to sterilize and permitting the family of the in-
competent and their physician (with or without the help of a review committee) to
make the decision without resort to the courts" [7].2
2 Annas also notes that there are three good reasons to distinguish involuntary sterilization cases
from the Quinlin decision [7, P 19]
64 S.T.Fry
A third approach is for individual courts to evaluate cases in which sterilization

of a mentally retarded individual is at issue and to authorize it only if it is in the per-
son's "best interests." This, of course, is the approach used in the Grady decision.
The fact that this decision and others like it are made on the basis of the best inter-
ests of the incompetent person leads me to believe that some courts have found a
new justification for authorization of involuntary sterilization: that of paternalism.
But is paternalism an adequate justifying principle for infringing the fundamental
right to procreate in mentally retarded persons incapable of expressing their own
voluntary choices in the matter?
3 Justifying Principles for Involuntary Sterilization of the Mentally Retarded
3.1 Paternalistic Principle
Paternalism is a liberty-limiting principle often invoked to justify state intervention

to benefit or to prevent harms to aperson. Acting paternalistically involves "over
riding a person's wishes, wants, or actions" [12]. Although there is reason to believe
that some examples of paternalism are justified, there is also some doubt as to
whether paternalism is an acceptable justifying principle for involuntary steriliza-
tion of mentally retarded persons.
John Stuart Mill considered paternalism to be unjustified as a liberty-limiting
principle, regardless of the conditions [20]. For a person to be justifiably coerced,
Mill thought it must be because his actions will do definite damage to others or
there is a risk of damage to another individual. For Mill, infringement of personal
liberty to protect a person from acts which do not violate public duties nor harm
anyone else is not morally justified.
Other theorists, however, have argued against Mill's position claiming that some
acts of paternalism are justified if they meet certain necessary conditions. Accord-
ing to Beauchamp and Childress, one condition is that the intervention "would
have to avoid an extremely risky circumstance where there are potentially serious
and irreversible consequences for the patient, as well as no available alternatives
that are likely to be more beneficial" [12, p 162]. Do decisions for involuntary sterili-
zation meet this necessary condition?
I say no. First, the use of the paternalistic principle for involuntary sterilization
with mildly and some moderately retarded persons does not avoid an "extremely
risky circumstance with potentially serious and irreversible consequences for the
patient." Pregnancy and parenthood are not any more risky for the majority of the
mildly retarded and some moderately retarded than it is for so-called normal indi-
viduals, nor do they entail serious consequences, especially for mildly retarded per-
sons [21-23].3 Furthermore, there are other alternatives available to mildly and
moderately retarded individuals in the form of contraceptive devices. Certainly the
use of contraceptives while retaining procreative capacities is of more benefit to
3 Anne T.Payne [21] gives a good discussion of how the mentally retarded are stigmatized by laws
that have nothing to do with parenti child relations
Involuntary Sterilization of the Mentally Retarded 65
mildly and some moderately retarded persons than the involuntary loss of a signifi-
cant and fundamental liberty right.
Thus, if the paternalistic principle cannot be shown to be morally sufficient as a
justifying principle to limit the liberty of mildly and some moderately retarded per-
sons, then we must look elsewhere for an adequate justifying principle to support
involuntary sterilization.
3.2 Harm Principle
The harm principle justifies coercive interference with a person's liberty where there
is reason to believe that his acts will result in physical or mental harm(s) to others,
whether or not these actions are within the control of the individual. According to
Mill, the only acceptable grounds for interfering with the liberty of actions of per-
sons is to prevent harms from occurring to others [20, p 13]. I support Mill's claim
that the harm principle specifies the only valid, moral grounds for intervention of
another's liberty. Yet this principle cannot be applied to the mildly mentally re-
tarded for the purpose of sterilization. Inbrder to do so, we would have to consider
that the bearing of a child by the mildly mentally retarded person causes harms to
others. And this is simply not true. The harm principle can only be applied to some
moderately retarded and profoundly and severely mentally retarded persons for the
sterilization to be justified. In these classifications of mental retardation, menstrua-
tion, pregnancy, or child-bearing would understandably involve significant psycho-
logical and physical harms to other persons, such as parents or caretakers. Because
mentally retarded persons as well as parents and caretakers may be harmed, the
fundamental right to procreate may be justifiably interfered with through involun-
tary sterilization. Thus, the harm principle allows involuntary sterilization of some
retarded individuals when it can be demonstrated that their involuntary actions
concerning procreating pose a significant risk of harm to others.
Application of the harm principle is therefore of interest to legislators and
courts who must adjudicate petitions for involuntary sterilization of incompetent as
well as competent retarded persons. A purpose of any legislation or court decision
regarding sterilization is to prevent the abuse of regulations whereby involuntary
sterilization can be allowed. Applying best interests standards is largely paternalis-
tic and not morally justified. Thus for legislators, the key to the entire matter is the
language used to satisfy substantive and procedural due processes as well as to
demonstrate the moral justifications for involuntary sterilization of incompetent
persons. Only in so doing can retarded citizens be protected from sterilization abuse
for the benefits of others.
66 S.T.Fry
References
1. Md Cir Ct (Maryland Circuit Court) Montgomery County (1980) re Flanary, No.67362. Mary-
land court rules it lacks the power to order non-therapeutic sterilization. Mental Disab Law Rep
4: 173
2. Miller RH (1981) Law allowing sterilization of retarded children is sought. Obstet Gynecol
News 16: 2, 27
3. Maryland House of Delegates (1981) Bill no. 1102
4. Maryland House of Delegates (1982) Bill no. 1850
5. Buck v Bell (1927) 274 U.S. 200
6. Lee Ann Grady (1981) 426 A. 2d 467 New Jersey
7. Annas GJ (1981) Sterilization of the mentally retarded: a decision for the courts. Hastings Cen-
ter Rep 11: 18-19
8. Johnson (1980) 263 S. E. 2d 805 North Carolina Court Appeal
9. Unfitness to care for child justifies sterilization in North Carolina (1980) Ment Disab Law Rep
259-260
10. Beauchamp TL (1977) Paternalism and biohavioral control. Monist 60: 71
11. Feinberg J (1973) Social philosophy. Prentice Hall, Englewood Cliffs, p25
12. Beauchamp TL, Childress JF (1979) Principles of biomedical ethics. Oxford University Press,
New York, p155
13. Roe v Wade (1973) 410 U. S. 113 ,
14. Skinner v Oklahoma (1942) 316 U.S. 535, 541
15. Gavvey SK, Shugar NB (1976) The permissibility of involuntary sterilization underthe parens
patriae and police power authority of, the state: in re sterilization of Moore Univ Maryland Law
Forum 6: 109-128
16. Shugar N (1979) The legal rights of handicapped persons with regard to procreation. Sex Pro-
creat 2: 216-230
17. ACLU to file class action for sterilized persons in Va. Ment Disab Law Rep 4: 275
18. Davis DD (1979) Addressing the consent issue involved in the sterilization of mentally incompe-
tent females. Albany Law Rev 43: 322-338
19. Coleman SS (1980) Involuntary sterilization of the mentally retarded: blessing or burden? South
Dakota Law Rev 25: 55-68
20. Mill JS (1956) On liberty. Bobbs-Merrill, Indianapolis, p100
21. Payne AT (1978) The law and the problem parent: custody and parental rights of homosexual,
mentally retarded, mentally ill and incompetent patients. J Fam Law 6: 797-819
22. Low intelligence of the parents a new ground for state interference with the parent-child rela-
tionship (1973) J Fam Law 374
23. Termination of the parent-child relationship: should parental IQ be an important factor? (1975)
Law Social Order 855
Informed Consent
A.J.Davis
In order to ascertain the role of the nurse in the informed consent process in in-
stances of research and treatment, 45 nurses were interviewed from two settings:
1. A public general hospital and
2. a private medical center.
This study falls into the category of descriptive ethics because it addresses the ques-
tion of what people actually do rather than what they ought to do. Underlying the
interview questions were two larger questions:
1. what do nurses see as their ethical obligation in the informed consent process and
2. how far does this obligation extend?
In most instances nurses have probably not been involved in the original phase of
the informed consent process. Therefore, they usually don't know what went on be-
tween the physician and the patient or b,etween researcher and the patient. In other
words, nurses don't tend to have a formal role in the informed consent process, al-
though they do witness the patient's signature at times.
But patients talk with nurses because they are often more accessible than other
members of the health care team. Therefore, nurses have a great deal of important
data about the patient, including his or her concerns, fears, lack of knowledge or un-
derstanding about his or her situation, etc. For example, suppose a nurse goes into a
patient's room and the patient says, "I'm going to surgery, but I really don't under-
stand what's wrong with me and what this surgery is all about, although I signed a
piece of paper saying that I did understand and that everything was OK. My doctor
told me that this operation is the best thing to do, but I was wondering if there were
some other things he could do first which would be less terrible and difficult."
The patient has given the nurse some information that no one else seems to have
and which throws into question the informed consent process. The first question
confronting this nurse is: Do I have any ethical obligations in this situation? Sup-
pose that she decides that, yes, she does have an ethical obligation to inform the
physician and does so. What if the physician says that he thinks it is unnecessary to
further explain to the patient, since the situation is very complex and difficult for
the patient to understand? The physician then does nothing. Now the second ques-
tion arises. Has the nurse met her ethical obligation to the patient by going to the
physician, although the situation will not change? In short, how far does the nurse's
ethical obligation extend? If this nurse believes that she has not met her ethical obli-
gation, then what should she do next?
Some of the major ethical principles in the Western philosophical tradition are:
autonomy, nonmaleficence (do no harm), beneficence (do good), justice, and verac-
ity (truth-telling). Although informed consent serves several important functions, its
basic function is to safeguard the patient's autonomy. We have a moral duty to seek
a valid consent because the consenting party is an autonomous person with all of
68 A.J. Davis
the entitlements that that status confers. Second-party consent is grounded in the
ethical principle of nonmaleficence, and it is appropriate only when the patient can-
not speak in his own best interest, such as when the patient is a young child or when
he is comatose, etc.
The elements of informed consent are based on the competence of the patient to
consent and include disclosure of information by the health professional, compre-
hension ofthe information by the patient, and, importantly, the patient's voluntary
consent. There has been some research on these aspects of informed consent. I shall
mention only a few such studies.
Bradford Gray, a sociologist, interviewed 51 women who were in another study
to determine the effects of a new labor-inducing drug. He found that although all
51 women had signed the consent form, 20 did not realize that they were in this drug
study. Many did not understand that there was some risk in being in the drug study,
and some did not realize that they could have said "no" to participating [1]. This
study by Gray points to the potential weaknesses in informed consent, which is the
major formal mechanism to safeguard patients' autonomy in instances of research
and treatment.
In another study, it has been-demonstrated that in order to understand the con-
tent of informed consent forms, one needs at least 3 years of education beyond high
school [2]. Many patients do not have this much education, so they cannot under-
stand the content in informed consent forms. This shows the extent to which health
professionals have difficulty disclosing information in a meaningful way. Such a
communication problem is functional in that it maintains the mal distribution of
power due to amount of information. In my own experience of several years as a
member of an institutional review board, I found the complexity of the consent
forms to be a major problem.
One of the problems in informed consent is the reality of paternalism in the
health care system. Paternalism occurs when someone else makes your decisions for
you in your own best interest, whether you would see it that way or not, provided
you had the data on which to make your own decisions. Paternalism violates auto-
nomy, since it reduced adults to the status of young children who cannot decide in
their own best interest because they have not developed cognitive skills or moral un-
derstanding. To decide for young children is appropriate, but paternalistic behavior
toward adults can be ethically justifiable only under limited and special circum-
stances.
John Stuart Mill, the nineteenth-century English philosopher, wrote:
The sole end for which mankind are warranted, individually or collectively, in in-
terfering with the liberty of actions of any of their number, is self-protection. He
cannot rightfully be compelled to do or forebear because it will be better for him
to do so, because it will make him happier, because in the opinion of others to do
so would be wise or even right [3].
Essentially, what Mill is saying is that we cannot advance the interests of the indi-
vidual by compUlsion, or if we attempt to do so, the evil involved outweighs the
good done.
And yet the health care system tends to be shot through with paternalism. Such
Informed Consent 69
behavior on the part of health care professionals makes life easier for them, since
they do not have to deal with the consequences of shared information. While pater-
nalism can serve in the immediate best interest of the professionals, it does not re-
spect the patient as a person. The reason we have such documents as the Patient's
Bill of Rights is because it is so easy to violate them. In health care ethics we speak
of vulnerable populations which include the mentally ill, the mentally retarded,
comatose patients, young children, fetuses, etc. But I believe that all patients are po-
tentially vulnerable. These brief remarks on informed consent are focused on only
one area of vulnerability.
For us in nursing, there are at least two basic questions:
1. What are the nurse's ethical obligations to the patient in the informed consent
process?
2. How far do these obligations extend?
References
1. Gray B (1975) Human subjects in medical experimentation. Wiley, New York

2. Alfidi R (1971) Informed consent: a study of patient reaction. JAMA, p1325-29
3. Mill JS (1962) Utilitarianism, on liberty and essays on Bentham. World, Cleveland
Issues of Confidentiality in Health Care
L.C.Greif
The purpose of this paper is to examine several questions that arise regarding con-
fidentiality of information. It has been a long-standing principle among physicians,
nurses, and other health care professionals that information from or about patients
and information from or about colleagues should never be disclosed or discussed.
This professional attitude was and is based on tradition, ethics, and law.
There are questions raised among health professionals asking if confidentiality
nowadays can be realized and is it truly a must. An argument on this controversial
topic could serve as an interesting opening to our discussion but I shall refrain from
such an argument because I sincerely believe that confidentiality is sine qua non in
the health professional patient relationship. It is well rooted in ethics and is go-
verned by law. Revealed information to other parties may lead patients, colleagues,
or others to personal, social, or occupational damages.
The issue I wish to raise now is privileged confidentiality. The physicians are
protected by privileged confidentiality. They are released from the obligation to tes-
tify in a court of law about thei~ patients unless the court orders otherwise; even
then the information is being held confidentially from the public.
The role and the status of the nurse has changed enormously - professionally
and legally. The patients enter into the nurse-patient relationship in expectation of
confidentiality; it is an essential element to the maintenance of their relationship.
But the nurse is still not protected by privileged confidentiality that recognizes the
unique nurse-patient relationship, though the confidences disclosed to her by the
patients are as personal and intimate as those revealed to the physician.
It may be interesting to mention that in the case of Mississippi Power and Light
Co. v Jordan [1] the court extended privileged confidentiality to a nurse because her
duties were performed in a role as an aide to the physician - a kind of extended
privileged confidentiality from the doctor to the nurse. That is not our aim. I think
that the nurses today have to put their minds to this issue and strive to achieve privi-
leged confidentiality.
Another issue is the professional nurse's autonomy in the domain of health edu-
cation and giving to the patients information needed for decision making and main-
tenance of health. Some nurses find it difficult to act appropriately in this autono-
mous role in spite of their impressive education in nursing and in biological and
behavioral sciences. Historical and psychological explanations can be given, but it
seems to me that there are two main reasons: first, fear of legal consequences which
may result because of autonomous action and second, fear of consequences within
the institution. The case of Tuma v Board of Nursing in the State of Idaho [2] in 1979
can serve as an example of one who took this personal risk. A patient told Jolene
Tuma that the physician did not discuss alternative cancer therapies with her. Tuma
discussed the prescribed chemotherapy and the alternative treatment with herbs
and nutrition with the patient and her family. She did not recommend any specific
treatment.
Issues of Confidentiality in Health Care 71
Did the nurse Jolene Tuma exceed the limits of the nursing role or did she just
perform her obligation and duty towards the patient? What about the patient's right
to know and to give informed consent? The hospital personnel complained that the
nurse was interfering with the physician-patient relationship. Her license was sus-
pended for 6 months. This verdict was reversed later by the Supreme Court in Ida-
ho.
I am more than convinced that it is the professional nurse's duty to give patients
information needed for maintenance of health and decision making. But the infor-
mation must be based on well-established communication and collaboration be-
tween physician and nurse. Otherwise, our claim that nursing should embrace
teaching and giving information to patients will be no less or no more than lip ser-
vice.
Another issue is raised: how much is one obliged to respect confidentiality in
the professional-professional relationship. Years ago the physicians used to enjoy
unquestioned support in all their deeds; they were protected by all the staff, includ-
ing the nurses. Today, the physician is no longer the "captain of the ship" and the
nurse is not a "borrowed servant" - professionally and legally. The physicians' and
the nurses' primary obligation is to serve the patients and to safeguard them. There-
fore, in some situations, reporting to a superior about an incompetent or negligent
colleague - be it a nurse or a physician' - is obligatory to protect the patient from
harm.
But what does a nurse do when the superiors do not act? Does she dare to act on
her own? Does she know that she is taking a risk of damaging her relationship with
the colleague and others, incurring a possible lawsuit for defamation, and engen-
dering possible unpleasant reactions of the institution, as arose in the case of Raf-
ferty v Philadelphia Psychiatric Center [3]. Linda Rafferty, a psychiatric nurse, re-
ported to her superior about the incompetent care given by the staff to patients over
a 5-year period. Because no action was taken she resigned and spoke out publicly
against the institution and the staff.
Several days after her employment as a supervisor at another psychiatric center,
an article about the conditions in her previous place of work appeared in a newspa-
per. Linda Rafferty was immediately discharged from her new post. An outspoken
nurse was persona non grata. She was protected in court because her charges were
true, and the aim of her report to the newspaper was in the public's interest.
It must be clear to all that confidentiality and secrecy cannot serve as a cover-up
for unethical and unprofessional behavior and for incompetent and negligent pat-
ient care. Of course, the nurse has to be loyal to her colleagues and to the institution
and voice her opinions through the official channels, but if they fail to act appropri-
ately she has no alternative but to act on her own.
However, it is our duty to strive to secure the nurses' authority to express opin-
ions about the quality of patient care for the benefit of the patient and the public at
large.
Another issue connected with confidentiality in the professional-professional
relationship are references given to nurses discharged because of incompetent nurs-
ing or unethical behavior.
The references often do not mention the reasons for terminating the nurse's em-
ployment and do not disclose any uncomplimentary remark. What are the possible
72 L. C. Greif
reasons for this behavior? I think that the main reasons are: the feeling of breaking
confidence and reporting colleagues, the good will to enable the nurse to get a new
start, the fear of a lawsuit for defamation, and the unwillingness to admit failing to
teach those nurses better nursing. This reasoning is unprofessional and misleading
to the prospective employer. Such attitudes must be changed. The superiors must
rid themselves of the feeling of conflict and give honest references based on' objec-
tive facts. The aim of honest references is to protect the public, the prospective insti-
tution, and the discharged nurse from potential harm. From the legal point of view
it is interesting to know that the Court of Appeals in New Mexico [4] held that when
a nurse applicant informs her prospective employer about her prior employment,
she has given consent for the prior employer to give the information about her as a
nurse. But it must be understood by both institutions - the requesting one and the
one providing information - that the information is of a confidential nature and
must be privileged and safeguarded.
I shall now refer to the most common breach of confidentiality and that is gos-
sip. The importance of confidentiality is stressed repeatedly in nursing education
and in service; the nurses are wl1ed that naive, well-meant gossiping may cause
irreparable and irreversible damage. It may result in a lawsuit and bring disciplinary
action upon the nurse.
An example can be given by' the case of Shaw v Glickman [5]. The lover, wife,
and husband were participants in the same psychotherapeutic group. The wife told
her husband that she was leaving him because she had someone else. The psychiat-
ric nurse divulged the lover's identity to the husband. The husband shot the lover.
The lover recovered and the case was brought to the court.
The astonishing part of this trial was that no issue was made by the court regard-
ing the nurse's breach of confidentiality, though this fact was well known to the
court. Why was this so? Was this behavior considered a routine nursing function?
Speaking about group therapy or group education, one must be alert to the issue
of confidentiality and secrecy of the group participants. They have no obligations -
legal or ethical.
Therefore it may well be an obligation ofthe professional to inform the partici-
pants of this potential risk. He should stress the necessity and importance of not dis-
cussing the names and the information revealed by the group participants and the
professionals outside the group. Of course, the professionals should be the model of
such responsible and confidential behavior.
The law recognizes the professional-patient relationship based on confidence,
because the entrusted communication really belongs to the patient and he is only
one who can give consent to divulge information.
The application of this obligation may be problematic sometimes: ethical dilem-
mas and legal questions may arise. The health professional may feel that revealing
information will be for the benefit of the patient, the other party, and in the interest
of the public.
An extreme but excellent example is the Tarasoff case [6]. A therapist revealed
the possible risk of dangerous behavior in a patient to the police. The therapist and
the police did not warn the possible victim or her family. The patient promised the
police to behave well. But the tragedy occurred and a girl was killed by the patient.
The therapist and the police were sued by the family of the victim for not revealing
Issues of Confidentiality in Health Care 73
the danger to the victim. In this case the Supreme Court decided that "the special
relation that arises between a patient and his doctor or psychotherapist ... may sup-
port affirmative duties for the benefit of a third person ..."
In contrast with this case is the aforementioned Shaw case (5]. The Maryland
court held that the behavior of the husband did not appear to the therapist to pose a
danger to the lover. There was no possible victim to be protected.
According to the law a professional has to behave in a way a reasonably prudent
professional would behave in similar situations and under similar circumstances.
There are situations and circumstances in which the professional will be legally jus-
tified to disclose information received from or about a patient for the benefit of an-
other party and the patient himself. The integrity of the professional-patient rela-
tionship can be protected by informing the patient that the information will be
revealed and why. Can a breach of confidentiality be morally justified? The variety
of life situations are unforeseeable; the code of ethics cannot supply specific an-
swers to specific situations. Each health professional must decide on his path as a
responsible ethical person.
Another issue is the health professional acting as double agent. Health profes-
sionals are appointed by the governm~t, schools, private agencies, and others to
treat their employees and students.
The professional may feel that he h~ a dual obligation: to the employer and to
the patient. The patient is of course expecting confidentiality that is morally and le-
gally due to him, and the employer is expecting to receive a full report about the
patient-employee. Even we as directors of schools or nursing services expect to re-
ceive reports from the personnel physician. It is doubtful whether the professionals
have the fortitude to refuse to communicate information about their patients to the
employer or are courageous enough to tell the patients that they may fail in keeping
all information regarding their health confidential. The problem of this is even more
complicated and problematic when dealing with psychiatric patients.
In case the health professional finds it necessary to reveal some information be-
cause of the benefit of the patient or others - as was pointed out in the aforemen-
tioned issue - the information must b~ safeguarded by the rules of qualified privi-
lege.
Another issue I wish to raise is whether a patient should have access to his own
medical records in certain circumstances? Has his lawyer access to his client's re-
cords - by patient's consent - in case he wants to investigate and make certain the
confidentiality is not used as an excuse?
In Israel, patients do not have this right in spite of the theoretically adopted atti-
tude that patients have the right to all information. The lack of the patient's access
to his medical records increases suspicion and does not help to clarify the case.
It may as well harm patients when they are under treatment in another hospital
or with another physician.
There are some legal and psychological reasons for not wanting to expose re-
cords. But the records are about the patient al)d they really belong to him. I think
that the existing approach should be changed and decided upon by various health
professionals and by the public and guarded by the law.
One may well define this issue as an international problem because of mobility
of people nowadays from country to country.
74 L. C. Greif
The last issue I want to mention is computerization in health care.

In some states health information about patients is computerized. In time it will
progress and will be in practice in most modem countries.
It seems that the leakage of information will be much greater through the com-
puterized data systems. Questions arise: Who will control those systems? Who will
be authorized to have legal access to this data? Will appropriate legislation be able
to protect this huge storage?
The problems mentioned here and many many others arising from this issue
must be discussed over and over again by health professionals, lawyers, ethicists,
computer specialists, and other experts with the aim of implementing administra-
tive, technical, legal, and other safeguards for the computerized health data infor-
mation system to protect the privacy and confidentiality of the patient and public at
large.
The discussions should be based on ongoing studies and researches done by all
the different disciplines mentioned above.
Most of the issues I raised now in regard to confidentiality and secrecy, and oth-
ers that I did not mention, were raised in the past; but they have to be voiced over
and over again until satisfactory directions and answers will be found.
It will be a long and painful process!
References
1. Mississippi power and light company v Jordan (1980) 143 So. 483 (Reprinted in: O'Sullivan AL
(1980) Privileged communication. Am J Nurs 80 (5): 947-950
2. Tuma v Board of nursing of the state ofIdaho (1979) 593 p 2d 711 Supreme Court ofIdaho (Re-
printed in: Bell NK (1981) Whose autonomy is at stake? Am J Nurs 81 (6): 1170-1172
3. Rafferty v Philadelphia psychiatric center (1973) 356 Supp 500
4. Gengler v Phelps (1978) 589 p 2d 1056, N Mex Ct App (Reprinted in: Greenlaw J (1980) Enforc-
ing professional standards. Nurs Laws Ethics 1 (10): 3, 7
5. Shaw v Glickman (1980) 415 A. 2d 625, Md App (Reprinted in: Greenlaw J (1980) Confidentiali-
ty - the psychotherapists nemesis. Nurs Laws Ethics 1 (9): 5, 8
6. Tarasoff v Regents of the university of California (1976) 551 p 2d 334 (Reprinted in: Greenlaw J
1980, ob at)
Father-Daughter Incest: Who Owns the Child?
M. deChesnay
1 Introduction
Now that the conspiracy of silence about incest has been penetrated, a number of
contradictory positions arise. Rights of the father, rights of the child, duties of fami-
ly members, duties of society, definitions of normality and deviance - all these
translate into issues with no easy resolution. When one person's rights conflict with
another's, whose take precedence? Who decides? We sometimes get stuck when we
try to place rights within a hierarchy. In the case of father-daughter incest, when the
daughter is clearly a victim and the father clearly an aggressor, as in infant rape, it
may be easy to resolve ethical conflicts or perhaps none arise. However, suppose a
teenage daughter contends that she is happy in her incestuous relationship with her
father? Maybe no harm appears in their relationship. Then people may ask whether
incest is all that bad. Some may say that only the effects are bad. Sometimes.
As a nurse-family therapist who treats families in which incest has occurred, I
felt obligated to make some attempt to understand more about fathers' justification
for their participation in incest.
1.1 Literature Review
With few exceptions, incest tabus are universal. That is, sexual relations between
culturally defined family members (within a kinship group) are forbidden. Brother-
sister and parent-child tabus are described everywhere. Noteworthy exceptions oc-
curred among ancient Hawaiians, Egyptians, and Incas, where brother-sister mar-
riages were sometimes arranged to preserve the supernatural powers of royalty.
Other exceptions were noted among the Balinese in the case of opposite sex twins
and when the children were defined as the property of the father (as Leach reported
of a tribe in southeast Asia [9]. Penalties ranged from definition of the incestuous
couple as crazy by the North American Plains Indians or banishment and humilia-
tion in Bali [9] to death, as in some Australian tribes and the Ashanti of West Mrica.
If the incest tabu is universal, then what is going on now in the United States,
where over 100,000 cases of incest are reported each year? That is believed to be a
conservative estimate of the incidence. Finkelhor [6] estimated that over one million
women have participated in incest with their fathers and an additional 16,000 do so
each year. Westermarck's biological and instinctual theories have been rejected by
contemporary anthropologists, though a revival of interest in them is being ex-
pressed in research on primates. The functional-structural theories of Malinowski,
Tylor, and Levi-Strauss [11] explain the incest tabu on the basis of the disruptive ef-
fect of competition within the kinship group (Malinowski) and the importance of
exogamous marital alliances to broaden the scope of social integration - marry out
or be killed out (Tylor and Levi-Strauss).
76 M.deChesnay
Despite the increase in frequency of articles and books about incest published in
the United States within the past 5 years, few of the articles report generalizable re-
search. Notable among the books published by clinicians is Herman's synthesis of
the literature and her own clinical interviews [7]. Kathryn Brady [41 Louise Arm-
strong [3J, Maya Angelou [2J, and Charlotte Vale Allen have desribed their own ex-
periences as victims of incest. In these books, as well as reported research by Bur-
gess et al. [5J, Herman and Hirschman [8J, Poznanski and BIos [13J, Miller and
Mansfield [12J, Spencer [14J, and Anderson and Shafer [1J, power is a dominate
theme. Janeway [10J attributed abuse of power in incest to patriarchal prerogative.
The notion that fathers can do anything they can get away with to their children is
supported by the hesitance of family members to disrupt the stability of the family
and by neighbors or public officials who are reluctant to interfere in family matters.
Here is where one ethical dilemma lies: the family is sacrosanct, so we don't want to
meddle; yet how can we prevent the abuse of family power? Who decides for the
child? What if the child appears to choose incest? Does the child really have a say?
Is it possible for a child dependent upon the family to have a free, informed choice?
2 Materials and Methods
In order to formulate a guide for practice with incestuous families, a research pro-
ject was designed to determine how incestuous and nonincestuous fathers and their
daughters perceive their rights and duties toward each other. It was hypothesized
that incestuous fathers and their daughters would say that fathers would have dif-
ferent rights than nonincestuous fathers and daughters.
2.1 Sample
Sixty pairs of fathers and teenage daughters were interviewed. These were selected
into three groups of 20 each: fathers and daughters in family therapy for incest, fa-
thers and daughters in family therapy for other problems, and fathers and daughters
not in family or individual therapy. The first two groups were randomly selected
from the investigator's case load at least 6 months after treatment was terminated.
The third group - fathers and daughters not in therapy - was selected within the
practice community. All subjects were informed of the nature and procedures of the
research and that their responses would be confidential. It was determined that the
study qualified for exemption status for review. Uncontrolled sources of error in-
cluded the use of one therapist's case load, the nature of self-reported research, the
exclusion of other family members' input, and the questionable randomness of the
third group.
Father-Daughter Incest: Who Owns the Child? 77
2.2 Instrumentation and Procedure
A structured interview was conducted with each individual, separately. Each person
was asked to answer several questions designed to elicit information about parental
and child rights and duties.
Content validity was established by the panel method, but construct validity was
not established. The reason is that it is nearly impossible to establish construct val-
idity on the first administration. Criterion-related validity was measured by corre-
lating responses on the rights and duties questions with the criterion of incest parti-
cipation. The correlation of participation in incest with rights and duties was 0.75.
Reliability was measured in several ways. The items were first treated as parallel
measures and a reliability of 0.56 was obtained. The split-halves method produced a
reliability of 0.86 for the total questionnaire. Finally, Cronbach's alpha was calcu-
lated and resulted in an internal consistency score of 0.89. It was concluded that the
test was reasonably valid and reliable.
2.3 Dala Analysis
Data were analyzed qualitatively and quantitatively. First, a typology of parental

rights and duties was constructed. Chi~square tests were performed to test the null
hypothesis that there would be no significant difference among the three groups of
incestuous pairs, non-incest therapy pairs, and nontherapy pairs. Alpha was set at
the 0.05 leveL A general linear model was tested to examine the variance in partici-
pation in incest. That is, participation in incest was regressed on the demographic
variables.
3 Results and Conclusions
3.1 Description ofSample
No significant difference was noted among the three groups of father-daughter

pairs on the socioeconomic variables of Amount of Father's Education, Total An-
nual Family Income, and Father's Occupation. Most fathers had some college edu-
cation, were employed in technical or nonmanagement jobs, and had a total family
income of between $25,000 and $30,000 per year. This income is somewhat mislead-
ing because it includes the wife's income, which in some cases exceeded the hus-
band's. Also, some husbands had wives who were unemployed.
Two additional items were measured and both showed high correlations with in-
cest. Incest fathers identified themselves as heads of housholds, whereas nonincest
fathers in both other groups tended to say they were joint heads of house with their
wives (r=O.64). Incest fathers also tended to use more alcohol than nonincest fa-
thers (r = 0.59).
No significant differences were found between the therapy clients and nonther-
apy clients on any of the items about parental and child rights and duties.
Significant differences were found between the incest fathers' perception of
their rights and duties and the other fathers on the following.
78 M. deChesnay
Incest fathers said that they had a right

1. To educate their children regarding sex
2. To act as head of house and be obeyed without question
3. To meet their sexual needs with their children
Incest fathers said they had a duty to be faithful to their wives and incest was de-
fined by them as not being unfaithful.
Nonincest fathers perceived that they had a right
1. To determine rules
2. To be respected
Regarding their children's rights, nonincest fathers differed significantly from incest
fathers on the child's right to own her own body. Incest fathers perceived that they
owned their children.
Nonincest fathers said they had a duty
1. To see that their daughters received appropriate sex education
2. To role model with the mother or other female partner
3. To set and enforce rules with the mother
4. To protect and provide for the family
Daughters engaged in incest perceived their fathers as heads of household and said
they feared their fathers, who were to be obeyed without question. Nonincest
daughers more often said their mothers were joint heads with their fathers and that
their fathers were respected rather than feared. Interestingly, no significant differ-
ences were found in comparing daughters' perceptions of their own rights on the
following:
1. The child should own her own body
2. Daughters should be protected from harm by parents
3. Children shouldn't have to use sex to bargain with their fathers
4. Children should be socialized into comfortable behavior by their parents
Nearly all the nonincest fathers and none of the incest fathers said these were chil-
dren's rights.
A general linear model was constructed to predict the variance in participation
in incest explained by the demographic characteristics. All demographic variables
acting together explained 68% of the variance, but only Head of House and Father's
Alcohol Use were significant at the 0.05 level. These two variables explained 62% of
the variance. Therefore, the null hypothesis that R2 = 0 was rejected.
From the data, it was concluded that
1. A significant relationship existed between fathers' perception of rights and duties
and participation in incest. Fathers who engaged in incest were more likely to jus-
tify their behavior on the basis of educating their children about sex, the father's
right to be obeyed, and the father's right to meet his own sexual needs. Incest fa-
thers said that they were not being unfaithful to their wives by engaging in incest
to meet sexual needs they claimed the wife would not meet. However, 78% of
these men admitted continuing to have sex with their wives and simultaneously
having sex with their daughter.
2. Regarding children's rights, the nonincest fathers tended to perceive that children
have rights, whereas incest fathers placed their own rights above those of their
children.
3. Participation in incest was predicted from knowledge of father's and daughter's
perception of father as head of household and alcohol use by the fathers. How-
ever, this finding should be interpreted cautiously. Though it is consistent with
findings by other researchers, notably Anderson and Shafer [1], no attempt to
show linear causality was made. Because of the limitations of my study, I am un-
willing to place much emphasis on this finding.
4 Implications
Implications for therapy with father-daughter incest families are that knowledge of
family members' perceptions of rights and duties might enable the therapist to gain
leverage in order to produce change. Fathers have legitimized authority in rearing
their children, but incest represents an ,encroachment upon the child's rights. The
child's right to her body supersedes the father's rights over the child. Fathers who
engage in incest with their daughters fail to perform their duty to protect their chil-
dren and to allow them to choose their own sexual partners freely. Therefore, fa-
thers engaged in incest may need to be confronted on how they place their own
rights and privileges above the rights of their daughters. Daughters may need to be
helped to learn nonvictim behaviors.
5 Recommendations
1. Admittedly, the investigator started with the bias that the child ultimately owns
the child. While precautions were taken to minimize the influence of this bias
during the interviews, the study should be replicated. Plans are underway to con-
duct a similar study by using the self-administered questionnaire method. Access
to clients is difficult in incest cases, but it would be valuable for a different inter-
viewer system to be implemented in order to facilitate interrater reliability.
2. Inclusion of other family members in the sample would give a clearer picture of
the family dynamics and the influences of the others on the father-daughter pairs.
3. Since no evidence was found to refute the research hypothesis that incest fathers
are different from nonincest fathers on the items measured, it seems legitimate to
incorporate assessment of perceptions of parental and child rights into family
therapy with incestuous families.
4. It would be interesting to ask the same questions about rights and duties of indi-
viduals engaged in other forms of incest.
5. The typology of rights and duties should be factor analyzed to assess construct
validity.
80 M. deChesnay
The notion that the female child owns her own body and that this right of the
child supersedes paternal rights is a fairly recent, radical position. The long tradi-
tion of parens patriae (the father owns his family) is a legacy from the Roman em-
pire. Currently, there are signs that fathers are showing interest in nurturing their
children. Too often, though, this new interest is expressed in struggles to reassert
patriarchal prerogatives: rights without duties. Male energies to do good things for
children are still balanced by power games with women. For example, the United
States Jaycees, who spend time and money raising funds for worthy causes (chil-
dren's hospitals and other), have recently turned back the clock and voted to sup-
port male dominance by expelling chapters that refuse to expel their women mem-
bers.
Abuse of women by men is a logical consequence of patriarchal family struc-
ture. Herman [7] says that as long as the power to dominate families is legitimately
given to men, then they have the power to abuse their children sexually. Most fa-
thers will choose not to exercise this power; but if one does, it is one too many. The
position I take with fathers in family therapy when father-daughter incest is the pre-
senting problem is, first of all, that the child's right to her own body takes preced-
ence over the father's rights to educate his daughter sexually and to meet his own
sexual needs. The notion that ch,ildren may appear to consent to incest fails to justi-
fy the father's behavior because children and fathers are not equals. The power dis-
tribution is skewed in favor of the father. Children dependent upon their fathers for
food, shelter, and the whole of family life are not freely consenting to incest. They
are merely submitting to what they see as an inevitable course of action. Fathers
who engage in incest with their daughters fail in their duty to act with respect for the
child's right to own her own body and to deal with their daughters in ways that en-
hance growth. Therefore, the first directive is to the father, and that is: The incest
must stop at once. If this directive is framed in a way that the whole family can ac-
cept, if the mother can be moved closer to the daughter, and if the father can be
taught the difference between nurturing and self-indulgend displays of affection,
then the potential is good for minimizing the harmful effects on the daughter and
promoting the health of the family.
References
1. Anderson LM, Shafer G (1979) The character-disordered family: a community treatment model
for family sexual abuse. Am J Orthopsychiatry 49 (3): 436-445
2. Angelou M (1970) I know why the caged bird sings. Random House, New York
3. Armstrong L (1978) Kiss daddy goodnight. Hawthorn, New York
4. Brady K (1979) Father's day. Seaview, New York
5. Burgess A, Groth N, McCauseland M (1981) Child sex initiation rings. Am J Orthopsychiatry
51 (1): 110-119
6. Finkelhor D (1979) Sexually victimized children. The Free Press, New York
7. Herman J (1981) Father-daughter incest. Harvard University Press, Cambridge, Mass
8. Herman J, Hirschman L (1981) Families at risk for father-daughter incest. Am J Psychiatry 138:
967-970
9. Hoebel EA (1958) Anthropology: the study of man. McGraw-Hill, New York
10. Janeway E (1981) Incest: a rationallook atthe oldest taboo. Ms 10 (5): 61-64, 77-78, 81,109
11. Levi Strauss C (1949) The elementary structures of kinship. Beacon, Boston
12. Miller V, Mansfield E (1981) Family therapy for the multiple incest family. J Psychosocial Nurs
Ment Health Serv 19 (4): 29-32
13. Poznonsky E, BIos P (1975) Incest. Med Aspects Hum Sexuality 9 (10): 46-76
14. Spencer J (1978) Father-daughter incest: a view from the correctional field. Child Welfare 57
(9): 581- 590
Prosecutors or Defenders: With Whom Should Clinicians Align?
S.A. Smoyak
There is an apparent, accepted splitting, or the assumption of a natural and expect-

ed conflict, between the mental health sciences and ethics - or between mental
health and social order or social reform. This division presumes that one cannot
"have it both ways" when deciding on whether a given act or behavior is illness or
sin. Tender, loving care and moral indignation are polar opposites; one cannot be a
therapist and a judge at the same time. When, as a therapist, one works with family
systems, as opposed to individual persons in treatment, the question of illness ver-
sus sin comes center front when a family member commits a violent act - even mur-
der - against another family member. When the law steps in, where does the thera-
pist step? On whose side does he or she align? With the prosecutor? With the
defender? With neither? Is neutrality really possible? Is neutrality useful? Short of
homicide, when a family membyr commits a societally deviant act (robbery, drug
dealing, other antisocial acts), what is the stance of the therapist with the family?
When the family is struggling over whether to give evidence to the prosecutor or
whether to plead for a public defender, how does the therapist act? What does he or
she do? What position is taken when parents ask for help in resolving their conflict
over extending, to an arrested child, forgiving love versus righteous judgment?
Clinicians, particularly those who work with families, are strangely silent in ad-
dressing these questions at conferences or in print. However, they are very much
discussed issues in case conferences and clinical staff meetings. Interestingly, while
there is passing mention and an occasional article [1] on records of therapists being
subpoenaed (or therapists, themselves), there is no systematic treatment of this sub-
ject, either.
In the literature, there are several thought-provoking articles on the ethical con-
siderations in serving as an expert witness. The accounts of dilemmas of expert wit-
nesses are "after-the-fact" accounts. The expert is called by the judge, the prosecut-
ing attorney, or the defense lawyer (public defender, perhaps) after a crime has been
commited or there is a civil suit in progress. (Parenthetically, the system of justice al-
luded to in this paper stems from the adversarial two-party method in English juris-
prudence. It would be fascinating to compare how other countries handle their
mental health and legal systems when they become intertwined.) While there are ar-
ticles about expert witnesses, there are none describing the situation in which a ther-
apist, working with an entire family, wherein one family member subsequently does
violence to another, chooses to align with the offense or the defense in the legal set-
ting. During the past 20 years or so, many more therapists have chosen to work in
the family mode. It is surprising, therefore, that there is this gap in the literature con-
cerning their involvement with legal matters involving their clients.
A nurse clinical specialist, who has been working with a family as their therapist,
is a very different type of expert witness. Her knowledge of human behavior, inter-
personal dynamics, and psychopathology in an academic sense is, under these con-
ditions of clinical involvement with the family, very much enhanced and expanded.
Prosecutors or Defenders: With Whom Should Clinicians Align? 83
McCormick [2] cited by McCary [3] provides a succinct summary of the qualifi-
cations of an expert witness:
An observer is qualified to testify because he has the first-hand knowledge which
the jury does not have of the situation or transaction at issue. The expert has so-
mething different to contribute. This is a power to draw inferences from the facts
which a jury would not be competent to draw. To warrant the use of expert testi-
mony, then, two elements are required. First, the subject ofthe inference must be so
distinctly related to some science, profession, business, or occupation as to be beyond
the ken ofaverage laymen; and second, the witness must have such skill, knowledge,
or experience in that field or calling as to make it appear that his opinion or infer-
ences will probably aid the trier offact in his searchfor the truth [2]. (italics mine)
It is generally assumed that it is not enough for a witness to qualify as an expert sim-
ply because he or she belongs to a profession to which the subject of the suit is relat-
ed. The expert witness must show further evidence of his or her special knowledge
about these particular matters at hand. This special knowledge may be obtained
from clinical practice or experience as well as academic training.
There are many allusions in the literature to the testimony of an expert witness
being challenged because the basis of his opinion has been formed in a very short
time. For instance, psychiatrists called to testify by a prosecutor frequently spend
only an hour or two with the subject, and in some instances rely only on case re-
cords and histories. Psychologists, while they tend to take longer performing a bat-
tery of tests, also spend relatively little time in forming an opinion. The nurse clini-
cian, then (or any mental health professional who has been serving the client or the
family), is in a far better position to help ajudge and jury decide what the truth is.
The answer to the question, "With whom should clinicians align in the legal pro-
cess?" is a most complicated one. At the most abstract level, the answer would be,
"With the position that will produce the most good, or the most beneficial results
for most of the parties involved, or justice." Of course, each of these ends - good,
beneficial results, justice - would need to have operational definitions developed so
common understanding would result.
In family contexts (or any human system, for that matter), the obvious problem
with the definition of "good" or "justice" is that what is good for one member may
not be good for another. One member's voiced rights frequently intrude upon, of-
fend, or violate another member's rights. For instance, a child's right to know, to be
informed, or to seek information frequently collides with a parent's right to privacy.
In working with families, the skilled and wise therapist attempts to seek solutions to
these problems of conflicting rights by moving the system to a new set of rules,
wherein both sets of rights are operative, or by establishing rules of the order of
turn-taking, boundaries, restructuring alliances, and other system strategies.
In other words, family therapy is framed as changing the system - changing the
rules by which the family is governing itself - rather than changing one individual
member. The client, in a sense, is the family system rather than the individual family
members. The therapist, however, respects and helps the development of each indi-
vidual member.
The legal system, however, never deals with family systems as such, but focuses
on persons. One person is a plaintiff or a defendant. Thus, a therapist must shift
84 S. A. Smoyak
gears and rethink "good" or "justice" from the context of what the expert testimony
will do to or for the family system in the light of what happens to the identified legal
subject.
Clinicians are called to testify in both criminal and civil proceedings. The latter
often come to court after lengthy, traumatic, and very hostile within-family wars,
such as divorce, custody of children, competency of adults to conduct their affairs,
and so on. The remainder of this paper will focus only on criminal cases.
When a family member is charged with a crime, and if the therapist chooses to
become involved (or is involved by the court by subpoena), he or she would choose
to align with the defender. No amount of mental gymnastics could produce ajustifi-
able case for a therapist to become adversary to a client in a legal setting.
Frequently people who have been charged with criminal acts, who are also men-
tally ill, are openly or subtly denied due process because the bedrock of our court
system, the adversarial process, is side-stepped. Too often (again, because of a lack
of systematic data, we cannot say exactly how often) prosecutors and defenders
agree that a person who has commited a violent crime is mentally ill (or was insane
at the point the crime was commited) and therefore cannot be brought to trial as a
sane person. In so doing, they have usurped the roles of judge and jury. Unless there
is a complaint or question raised by some other person or organization (e. g., a fami-
ly member, public advocate, mental health association, etc.), the accused person
moves from jail to mental hospital, undergoing a subtle transformation from ac-
cused to condemned, without due process.
Parenthetically, there are several recent articles focused on a related issue - the
reification of psychiatry as a profession. Concern is expressed that in the past too
much reliance on psychiatrists' opinions has resulted in a distortion of justice.
Gardner claims that there are "faint signs of a movement away from exessive reli-
ance on medical judgments in determining criminal responsibility" [4]. Too much
faith in psychiatry has "resulted in a perversion of some of the ideals of criminal
law, particularly of the principle that the jury, as the conscience of society, should
make the moral determination of criminal responsibility"[4].
When persons charged with criminal acts are also thought to be mentally ill,
what follows is a very ad hoc, loose, ill-defined sequence of decisions made - all
outside the courtroom - of competency or not, illness or not, need for confinement
or not, harmfulness to self and others or not, and so on. The deciders are ward phy-
sicians in state and county mental hospitals (often not even psychiatrists), expert
witnesses called by the judge (almost always psychiatrists), or superintendents of in-
stitutions (who, today, might be hospital administrators rather than mental health
professionals).
The following case will illustrate the dilemmas when the mental health system
and the legal system become interlocked. In an old, very traditional community in
New Jersey, there was a highly respected Italian Catholic family. The father was a
physician, having conducted his general practice for more than 40 years, and was al-
so active on the school board and in other civic activities. The mother fit the picture
of a traditional homemaker, also active with the school and extended family respon-
sibilities. The first child was a son, also a physician. The second was a daughter,
who was identified by the family as "the problem". The third child, also a daughter,
was a nurse. The "problem child," whom we'll call Rosa, was, at the time, 26 years
old, unemployed, and spending most of her time closeted in a third-floor garret
bedroom in the family mansion. When I first met her, she was lying on a bare mat-
tress on the floor, covered entirely by quilts, in the attic room where the June heat
had produced readings of 94F, even at 9:00 p.m. My monologue of introduction
to her, since she for the first hour said nothing (not even emerging from under the
quilts), included my identity ("I'm a nurse"), how I got there ("Your family called
me to help"), and my position ("From what I can see, things must be miserable for
you. Talk to me, so we can figure out what to do.").
Condensing a long, slow, tedious process into a brief summary yields the follow-
ing: When Rosa joined her mother and father and siblings around the dining room
table on the first floor, it became quite clear that she was the classic signaler of fami-
ly distress. While she had some very obvious symptoms and had even earned diag-
nostic labels on previous hospital admissions, such as "paranoid schizophrenic"
and "drug-dependent, depression psychosis," she clearly was the truth-sayer in the
family. With her inappropriate affect and thought-disordered speech, she was able
to name and to describe the various family hypocrisies, shams, and pathologies.
These included pseudomutual pacts among the paternalistic extended family, op-
pression of women in both generations (for instance, her father had forced her to
have an abortion, although she was opposed to this), drinking problems in mother
and brother, inability of the children to'confront the parents, coalitions across gen-
erations of both Rosa and mother and Rosa and father (which switched with light-
ning frequency), and so on.
I identified several family strengths, which were verified by the family: (a) al-
though the "truths" were voiced in a somewhat strange fashion, Rosa had suc-
ceeded in getting help for the troubled family; (b) the youngest child (24-year-old
RN) seemed able to escape the pathological dynamics in a somewhat easier manner
and seek outside resources; and (c) the aging parents (father, 70 years old); mother
61 years old) were at their wits' end and eager for respite.
One of the first goals was to stop all medications for Rosa. Among other prob-
lems, Rosa was the clear victim of iatrogenic disease. From the time she was a very
little girl, her physician father had given her drugs inappropriately. For instance,
when she awakened from a bad dream and went to the parental bed, crying in ter-
ror, he gave her phenobarbital to get her back to sleep. By the time she was an ado-
lescent, she was helping herself to various psychoactive agents in her father's well-
stocked office, which was a part of the family home. When things got out of hand
and he felt he could not control her drug use, he hospitalized her. When she protest-
ed hospitalization, she was given electroshock "treatments." At several points, when
she behaved in a bizarre fashion at home, her father and brother together slipped
liquid chlorpromazine into her beverages. When I met her, it was truly impossible to
evaluate the nature of any mental illness because of the confounding picture pre-
sented by the drug abuse.
After a case consultation within the department of psychiatry, the father agreed
to stop all medication, with the one exception of an intramuscular dose of fluphena-
zine. My clinical judgment is that Rosa perceived that this was a truly different situ-
ation now. In the past, her father had threatened to cut off her drug supply and had
hidden keys and the drugs, themselves. This time, however, was different. Rosa de-
manded her daily supply of "uppers"; her father refused. She grabbed a kitchen
86 S. A. Smoyak
knife and killed him, stabbing him several times in a tussle which occurred on the
street in front of the house.
Dozens of questions about due process, justice, and rights can be generated.
Rosa was arrested immediately and placed in the county jail. Her younger sister
telephoned me and asked me to come and help; her brother could not be found and
her mother was hysterical. During the 40-minute ride to this family's home, I tried
to sort out what position I would take and what actions of mine would best serve the
various family members' needs. The specific questions that highlight the dilemmas
when the legal and mental health systems intertwine are these: Who decides to
transfer an arrested person from jail to a mental hospital? (The fact that this murder
occurred on a weekend further complicated matters.) Who informs the arrested per-
son of his or her rights? Is there an equivalent Miranda ruling for mental patients?
Who decides that the person is "unfit to stand trial"? Who has what information
about the series of decisions relating to disposition? What does the patient know?
What do the family members know? Who is in charge of telling? Who decides that
the patient can be transferred from the tight-security ward for the criminally insane
to a less restrictive ward in a mental hospital nearer the patient's home? What is the
interaction among the family therapist, the judge, the prosecutor's psychiatrist, the
public defender, the ward psychiatrist, and family members?
For all of these questions, the common response is that things proceed in an ad
hoc, rather than a predictable, manner. In this particular case, even though I had the
closest and most detailed knowledge and understanding of this family's dynamics
and Rosa's specific act of violence, my inputs have been treated very (gingerly) hes-
itantly by the legal sector. The public defender did obtain a signed release of infor-
mation from Rosa, and I did copy and forward my clinical records to him - but I
have no evidence that this has made any difference in the decisions made to date. I
have visited Rosa in the criminal ward and have had joint (with the ward psychia-
trist) and individual sessions with her. How the content of these sessions will be
used in court - if she ever comes to trial - is impossible to say.
At this time, the mother is in another mental hospital, voluntarily admitted to in-
tervene in her problem drinking. I have had two family sessions in that hospital -
with the adult children (not Rosa, of course), that psychiatrist, and an alcoholism re-
habilitation counselor. My attempts to get the total family together for a future plan-
ning session have been unsuccessful. The roadblocks are both in the area of Rosa's
present legal status and in the fact that the private hospital staff is largely disin-
clined to physically move themselves to the state hospital for a session.
In this instance, then, the clinician's prior knowledge of facts and events and her
prior diagnosis of family pathology could be indispensable to legal truth-seekers.
The ambiguity of the actual disposition, however, reflected in the questions I laid
out above, have prevented open, clear, rational decision making.
In another murder case, which ironically is proceeding much more straightfor-
wardly, I am the prosecutor's witness. In this case, a woman killed her husband by
stabbing him in the back several times as he was leaving his mother-in-Iaw's home.
My decision to align with the prosecutor was made on the basis of my review of the
arrest record, the interviews of the defendant recorded by others, my interview with
a clergyman who knew the couple, and my knowledge about battered women. It
was my judgment that this woman's defense that she was a battered woman was not
substantiated by the recorded data. Ironically, my testimony is sought after much

more enthusiastically in this instance than in the other, although here I am an after-
the-fact witness.
In conclusion, the activites of mental health professionals in the legal sector
have received considerable attention in the literature. Their usefulness and the rele-
vance of behavioral science information and the testimony of expert witnesses have
been widely debated [5]. Ethicists raise questions about their impartiality or objec-
tivity. My position is that the most useful expert witness is one who has prior clinical
knowledge of the situation. One may label this "bias"; I prefer to see it as expanded
awareness. Diamond has also expressed disbelief that witnesses can actually be
neutral or impartial experts. He states:
It is a fiction of the law that only the immediate parties to a legal action - the defendant and the
plaintiff or prosecutor and their counsel - are adversaries. All else: the judge, the jury, and the
witnesses, are not to be partisans. All witnesses, both expert and lay witnesses of fact, are sworn
to tell the truth, the whole truth, and nothing but the truth. This truth, as revealed in the testimony
of the witness, may favor one or the other side, but the witness may not. That this is a fiction, not
a reality, is evidenced by the customary manner of labeling witnesses as for the defendant or for
the prosecution.
I will thus concede at the outset that the expert witness called by either adversary is likely to
be biased to some degree, that his opinions are not truly impartial, and that he, himself, as a party
to the adversary system, becomes to a certain degree an advocate. I concede this with full aware-
ness that both legal and medical codes of ethics demand the impartiality of the expert witness,
irrespective of the side that calls him. The desirability of such an ethical ideal must not blind us to
the reality fact that the ideal is seldom, if ever, achieved [6].
Given that mental health professionals do become involved with the legal system,
the following guidelines are offered in the spirit of keeping honesty a chief opera-
tive value.
1. Examine your conscience. Toward what end do you see your energies being ex-
pended? To protect your patient's rights or to gather personal fame and fortune?
2. Carefully track the exposition of facts and the sequence of events. What was your
clinical opinion at what point in time? Do you detect subtle changes in your
thinking as the case unfolds?
3. Be committed to ongoing peer review. Have you used a clinical case conference
or "rounds" to expand your thinking? Have you sought inputs of differing per-
spectives and opinions? Have you shared your thoughts and experiences in pub-
lished form?
In sum, since neutrality is not possible when the mental health and the legal systems
become intertwined, then honesty is the value to be espoused. Clinicians must com-
mit themselves to an ongoing process of both soul-searching and cognitive expan-
sion.
References
1. Gansheroff N, Boszormenyi-Nagy I, Matrullo J (1977) Clinical and legal issues in the family
therapy record. Hosp Community Psychatry 28/12: 911-913
2. McCormick CT (1945) Some observations on the opinion rule and expert testimony. Texas Law
Rev 23: 109-136
88 S. A. Smoyak
3. McCary JL (1950) The psychologist as an expert witness in court. Psychol 11/1: 8-12
4. Gardner M (1976) The myth of the impartial psychiatric expert - some comments concerning
criminal responsibility and the decline of the age of therapy. Law Psychology Rev 2: 99-118
5. Anderten P, Stauicup V, Grisso T (1980) On being ethical in legal places. Professional Psychology
11/5:764-773
6. Diamond B (1959) The fallacy of the impartial expert. Arch Criminal Psychodynamics 3/2:
221-235
III. Nursing: Ethical Aspects
Introduction
The papers that make up this section on the ethical aspects of nursing can be
divided into five parts:
1. Moral dilemmas in nursing
2. Ethics in educating
3. Nursing research and ethics
4. Ethical decision making
5. Ethics and treatment
In order to ensure adequate, professional nursing treatment for patients, are ethical
standards and professional judgment sufficient? Or, are regulations necessary?
Legislating codes of conduct may be beneficial as well as an impediment. Add to
this moral dilemmas - dilemmas that are implicit in all the helping professions -
and we are faced with a possible philosophical impasse.
Given the capacity for choice, moral/ethical conflicts are inevitable. Can we ed-
ucate nurses to be ethical? Are there specific teaching strategies that can be employ-
ed in order to inculcate nurses with an ethical posture? Are ethics learned on the job
or in a theoretical manner? Are ethics born or bred - the old nature versus nurture
controversy.
The ethical issue becomes more pronounced when dealing with nursing re-
search. The subject, agency, and researcher must be protected: is this possible prac-
tically? What about the ethical orientation of the researcher; this may affect re-
search guideline principles and possibly create potential problems. The type of
research (interviewing, participant observation, ethnographic, etc.) may also deter-
mine whether there will be an ethical conflict. The field of nursing research does
have its potential problems, and these must be thoroughly explored in order to min-
imize the inevitable conflict areas.
Decision making is intricately bound up with the issue of accountability. Re-
sponsibility brings with it rights and obligations - to patient, self, and society. The
authority-autonomy dimension has an impact here in order to insure a responsible
choice. So, too, do the social and role constraints that are imposed on individual
nurses. This must affect the ethical decision-making process. Ethical role models
and simulation games are two of the possible avenues suggested for raising the level
of moral judgment.
In the ethics and treatment part of this section, the ultimate philosophical pur-
pose of nursing is examined. Quality of care, treating terminally ill patients, eutha-
nasia, care of the elderly, and death and dignity are some of the issues explored. The
countertransference reactions of nursing staff are also related to.
This section on the ethical aspects of nursing includes contributions from Cana-
da, England, Israel, Norway, Scotland, Spain, Sweden, and the United States.
Moral Dilemmas
Moral Dilemmas in Nursing

A. V. Campbell
1 Introduction
George Bernard Shaw, in his biting, yet perceptive, preface to The Doctor's Dilem-
ma, had this to say about the medical conscience:
Doctors are just like other Englishmen: most of them have no honour and no conscience; what
they mistake for these is sentimentality and aIJ intense dread of doing anything everybody else
does not do ... [1, P 229]
In that same preface GBS made the often-quoted remark that "all professions are
... conspiracies against the laity" [I, p 236]. Now, far be it from me, a mere Scots-
man, to make any comment on an Irishman's assessment of the morality of the
English! Much more interesting is Shaw's suggestion that medical ethics may be
empty convention at best, and, at worst, a kind of humbug designed to conceal the
profession's shortcomings from the public. Eliot Freidson makes a similar point,
though rather less elegantly: " ... a code of ethics may be seen as one of many meth-
ods an occupation may use to induce general belief in the ethicality of its members,
without necessarily bearing directly on individual ethicality" [2].
Might such suspicions be harbored about nursing ethics 1 Are they the product
of that "last temptation" described by T. S. Eliot, "To do the right deed for the wrong
reason" [3]1 In this paper, I shall look very briefly at this question by observing
changes in the character of published codes of nursing ethics in recent times. In par-
ticular I shall compare the 1973 version of the International Council of Nurses
(ICN) code 1 with the 1965 version2 (itself a revision of the first ICN code, adopted
in 1953). I shall also refer to two national ethical codes: the American Nurses Asso-
ciation (ANA) Code for Nurses (1976) [4] and the Royal College of Nursing of the
United Kingdom (RCN) Code of Professional Conduct [5]. My purpose will be to
assess the adequacy of these codes as statements of disinterested moral concern for
human well-being by looking at the way they describe professional responsibility.
In a short concluding section I shall suggest ways in which the "conspiratorial"
character of professionalism might be avoided, not merely by redrafting codes but
by changing styles of professional education and practice.
1 Adopted by the Grand Council of the International Council of Nurses (l CN) meeting in Frankfurt,
Germany, June 1965
2 Adopted by the ICN Council of National representatives in Mexico City in May 1973
94 A. V. Campbell
2 Professional Responsibility
The 1973 version of the ICN code differs from the earlier versions in two important
respects:
1. Phrases like "belief in the preservation of human life" and the "fundamental re-
sponsibility to conserve life" are replaced by "respect for life" and "the respon-
sibility to prevent illness and restore health" and
2. references to carrying out physicians' orders are removed and a new stress on the
nurse's own professional judgment is introduced.
To some extent both of these changes seem to reflect the increasing desire to see
nursing as a profession in its own right, rather than in the "handmaiden" role to
medicine, in the Florence Nightingale tradition. The deletion of any reference to
doctor's orders makes an interesting contrast with the following extract from the
British Red Cross Society's Nursing Catechism [6] - a little family heirloom of mine!
Q. What is the Nurse's duty to the Medical Officer?
A. Absolute loyalty, prompt obedience, and quickness in observing and reporting
any change in the patient's condition.
Equally, the move away from an absolute responsibility to conserve life to respect
for life and responsibility for prevention of and recovery from illness gives the nurse
a much more active function in health care. (The phrase "respect for life" echoes the
change in the medical ethical codes from the prohibition of abortion and euthana-
sia of the Hippocratic Oath to the broader phrase "the utmost respect for human
life from the time of conception" of the World Medical Association Geneva Con-
vention Code of 1949). Both in relation to the doctor and in relation to the patient,
the nurse is being encouraged to a greater exercise of independent professional
judgment.
But now the question must be asked: Is this increase in professional responsibil-
ity an improvement in the morality of nursing practice? Are we seeing here anything
more than the hardening up of yet another conspiracy against the laity? In this con-
text the codes of the ANA and the RCN make very interesting reading. Both of
these codes have a marked emphasis at the very beginning of their statements on the
autonomy of patients or clients. The formulations they use are worth quoting in full.
The RCN code states:
Nursing care should be directed towards the preservation, or restoration, as far as
is possible, of a person's ability to function normally and independently within
his own chosen environment [5, II, 1].
The ANA code, speaking of the "self-determination of clients" states:
Each client has the moral right to determine what will be done with his/her per-
son; to be given the information necessary for making informed judgments; to be
told the possible effects of care; and to accept, refuse, or terminate, treatment [7].
Both codes also recognize the difficulties in such an emphasis on patient/client au-
tonomy. The RCN code discusses problems in coping with violent patients and the
ANA code mentions situations in which individual rights to self-determination may
Moral Dilemmas in Nursing 95
"temporarily be altered for the common good." Nevertheless the emphasis remains
striking. In such formulations the self-limiting nature of professionalism is given
prominence. Control is handed back, as fully and quickly as possible, to the person
receiving nursing care. It is not (apparently) monopolized by the profession by the
usual strategy of hiding behind the "medical mystique."
Thus we see an important tension between professional autonomy and patient!
client autonomy. Which of these two values does the increasingly self-reliant profes-
sion of nursing truly seek to serve? Can it serve them both at once? In considering
this, we need to step back for a moment from the specifics of nursing ethics to more
general issues of the nature of moral theory.
Morality can be distinguished from mere social convention only if, and when, it
attempts to transcend partisan interests. A morality which simply underwrites the
power of the stronger over the weaker is no morality at all, but merely (as Shawob-
served) a conspiracy. Another way of putting this point is to say that disinterested-
ness is the essence of morality. (This was well observed by Emmanuel Kant when he
described "universalizability" as the distinctive feature of morallaw. 3) To expouse a
moral principle is to regard some actions as right, whether or not they work to one's
own personal advantage or to the advantage of a group of which one is a member.
Of course, at a practical level, total disinterestedness is rarely possible and perhaps
not even desirable, since it could result'in very cold, emotionless relationships. But
still the avoidance of bias and partisanship must be been as the fundamental aim of
morality.4
Returning now to professional ethics - and codes of nursing ethics in particular
- we can see the difficulty of assessing their moral worth. Although such codes use
high-sounding phrases like "service to mankind" (lCN code, 1965) and "respect for
dignity and rights" (lCN code, 1973), there is surely no denying that they are also
formulated to serve partisan interests. Baldly stated, they are the attempts of a pro-
fession to say to the public "you can trust us" and to other professions "give us the
respect we deserve." Moreover, professions like medicine and nursing are occupa-
tions which make money out of people's misfortune. There is profit in being trusted
as a healer and helper. ("There's gold in them thar ills," as Tom Lehrer put it in "The
Ballad of Sigmund Freud".) Certainly it would be surprising if anyone entered
nursing with dreams of riches, given the very modest salary levels which the profes-
sion commands, but nonetheless being seen as morally trustworthy is an element in
ensuring the livelihood of the professional nurse.
Thus if nursing is to be seen as a moral enterprise, not only a way of making
money and of gaining social status, it is essential that the aims to which it is commit-
ted can be shown to possess independent moral worth. Take as an example the for-
mulations of the 1973 ICN code: "promote health, prevent illness, restore health,
alleviate suffering." These are more than empty rhetoric only if nursing skills can
achieve them. Nursing will achieve them if it is genuinely on the patient's side, argu-
ing against all that is health-denying. This may well mean controversy and debate
3 For an exposition of Kant in relation to medical ethics see Campbell [8]

4 Not all ethical theorists would agree with these views, of course. Some (the ethical egoists) argue
that personal advantage in the only possible goal and others (the utilitarians) that the benefit of the
majority must be normative
96 A V. Campbell
with other professions and with sociopolitical forces. The professional skill ofnurs-
ing may help the patient regain control of his/her own disordered body and/or
mind and emotions, may help with coping with disability,so that it ceases to be a
handicap, may help in controlling or transcending pain and anxiety and in facing
unavoidable death with full awareness and with peace of mind. The nursing profes-
sion will deserve respect and trust only to the extent that its search for independent
responsibility has such disinterested achievements for the patient in view. It must
show that a gain in autonomy for the profession is also a gain in autonomy for those
who seek its help.
9 Ethics in Practice
By way of illustration of what I have been saying, I will conclude with a short case
illustration. The case is taken from Dilemmas ofDying, edited by I. E. Thompson [9].
Like so many such illustrations it is, I fear, an object lesson in what should not be
done.
Death of a Schoolboy
David, a schoolboy of 13 years, was the only child of middle-aged parents. One
day he was severely injured in. the spine as the result of a playground accident at
school. When admitted to a paediatric neurosurgical unit it became quickly evi-
dent that the damage to the spine was so extensive that David would almost cer-
tainly be totally paralysed from the neck down. The boy was fully conscious and
obviously very anxious about his condition. Mter a few hours, his breathing de-
teriorated rapidly and it became necessary to put him onto a respirator, after per-
forming a tracheostomy under local anaesthetic. At this point David's parents ap-
proached the Consultant and asked whether there was any hope of David
avoiding total paralysis. They were told that there was virtually none. They then
suggested that no further effort should be made to maintain David's life, because
they regarded his condition as one which the boy could never tolerate.
The medical staff were surprised by this request but eventually agreed that
David should be taken off antibiotics and given increased sedation. However, the
night nurse on duty that night withheld the medication because she was opposed
on conscientious grounds to giving sedation unnecessarily. At the request ot: the
consultant, this nurse was removed from the case and the regimen was continued.
At no point was the boy told what was happening to him or what his true con-
dition was, and when he asked a nurse if he was dying this was vehemently de-
nied. Mter about a day or so he died of respiratory failure. 5
Much could be said about what was wrong in this case, but I will restrict my com-
ments to three points regarding autonomy:
1. David's loss of autonomy from the accident was compounded by the actions and
attitudes of the parents and the professional staff; he was deceived, sedated out
of awareness, and hastened to death to satisfy other people's judgments of what
was best for him.
5 Based on a case reported in Thompson [91

Moral Dilemmas in Nursing 97
2. The nurse who refused to cooperate in this was simply removed by medical au-
thority, without, it seems, her protest having any effect.
3. The professional staff surrendered their professional autonomy to the parents, ac-
ceding to their request as though they were the patient to whom they owed ser-
vice.
The case illustrates well the potential future significance of a more articulate and
morally educated nursing profession. Conscientious objection by a nurse should
lead to a proper debate about the morality of the procedures being carried out, and
professionals who are willing to treat individuals as objects to be manipulated (with
whatever good intentions) should be open to radical challenge by their colleagues.
If the codes of nursing ethics genuinely mean what they appear to say, then a first
priority in nurse education would have to be an intensive and sustained exposure to
moral education. Awareness of the patient's own self-understanding, ability to criti-
cize set routines, and articulateness in voicing objections to the decisions of others
would become skills of equal importance to the many now included in training. If
nurses aspire to be moral advocates on their patients' behalf, not simply instruments
of medical decision making, then they must learn at least something of the art of
both moralist and advocate. Otherwise the claim to a professional autonomy based
on disinterested moral commitment to Ntients is just rhetoric.
Earlier in this paper I quoted some words from T. S. Eliot's Murder in the Cathe-
dral. I would like to end with some more mysterious words, from his Four Quartets
[10]. These words suggest, in paradoxical fashion, that a nurse who was fully con-
cerned with the health of people could well feel a stranger in a too-simple world of
tranquilized anxiety and scientific medical cure:
Our only health is the disease
If we obey the dying nurse
Whose constant care is not to please
But to remind of our, and Adam's curse,
And that, to be restored, our sickness must grow worse.
You will, I hope, forgive so enigmatic an ending. The theologian will out!
References
1. Shaw GB (1971) Collected plays with their prefaces, vol 3. The Bodley Head, London
2. Freidson E (1975) Profession of medicine. Dodd, Mead, New York, p 187
3. Eliot TS (1957) Collected plays. Faber and Faber, London, p 30
4. Reich WT (ed) (1978) Encyclopedia of bioethics, vol 4, appendix. Macmillan and Free Press,
New York
5. Royal College of Nursing (1976) Code of professional conduct. The Royal College of Nursing
of the United Kingdom, London
6. The British Red Cross Society (1929) Nursing catechism, question 2. Cassell, London
7. American Nurses Association (1976) Code for nurses, Interpretive statement. American Nurses
Association, Kansas City
8. Campbell A (1975) Moral dilemmas in medicine, 2nd edn, chapts 4,5. Churchill-Livingstone,
Edinburgh
9. Thompson IE (1979) Dilemmas of dying. Edinburgh University Press, Edinburgh, pp 127
10. Eliot TS (1959) Four quartets. East Coker, stanza IV. Faber and Faber, London
Law or Ethics: Which of Them Should Regulate
Nursing Practice?
I.H.Haugen
There seems to be general agreement upon the necessity of some steering mecha-
nisms in the health field and for a system regulating the practice performed by
health personnel. The two main reasons for this need are:
1. To secure the patient's safety and

2. to provide status for the health professions.
In this paper different ways for controlling practioners will be discussed. "Laws and
regulations" will be used synonymously with "legislation".
In most countries there exist similar laws and regulations which regulate plan-
ning, financing, and administrative responsibilities of the health services. The exist-
ing legislation concerning nursing and medical practice shows, however, great vari-
ation from one country to another. The differences may be due to variations in
religion, culture, and political systems, but also countries with great similarities
have different systems for regulating the practice of the health professions.
For instance, the World Health Organization's Report on Legislation Concern-
ing Nursing/Midwifery Services and Education shows the differences within the
European region [1].
In most countries in the region nursing practice and titles are restricted to hol-
ders of the appropriate diploma. In addition a nurse, in the same way as a physi-
cian, has to obtain a license or have her diploma registered. The license to practice
or a nurse's registration can be withdrawn under conditions specified in legislation.
Professional misconduct, gross incompetance, abuse of dependence-producing
drugs, alcoholism, physical or mental impairment, or criminal offenses are the most
common reasons for withdrawal of the license or registration. In case of malpractice
the nurse may even be brought before the court. Under which conditions this may
be happen is, however, not the subject of this paper. In the European region most
countries also have listed functions and duties which nurses are competent and al-
lowed to perform. The purpose of these lists is to prevent nurses from performing
activities which may hurt or injure the patients.
There are no lists of duties or functions which the nurses are obliged to perform
for the safety of the patient. Lists of activities which physicians are allowed and
competent to perform are not known to exist (at least not the same extent). Thus it
seems that as far as physicians are concerned, the practitioner's own judgment
about personal competence is accepted by the lawmakers. This acceptance is not
true when it comes to the practice of the nursing profession.
This is also the situation in many countries in other parts of the world. Studying
the definitions and the lists offunctions and duties which express the legal status of
the nurse would probably be very provocative reading. The lists of duties are usual-
ly exhaustive and consist of detailed technical procedures and activities which a
Law or Ethics: Which of Them Should Regulate Nursing Practice? 99
nurse is allowed to perform alone, under a physicians prescription, or sometimes

only in his presence. The duties are presented both positively and negatively, i. e.,
both the activities which a nurse is authorized to perform and the forbidden acts are
listed. One characteristic worth mentioning is that in legislation with detailed provi-
sions, including exhaustive lists of duties and functions, nurses are more explicitly
placed as assistants to physicians than in less specific provisions.
In all countries physicians are responsible for the medical diagnosis and pre-
scription of treatment. The nurses may, however, be the ones who implement the
treatment ordered, including the observations of the patient. It has not yet been ac-
cepted in the legislation that these two tasks are mutually interdependent and are of
equal importance to the patient. Rarely is the independant care concept of nursing,
which is much more than technical implementation of ordered treatment, expressed
in any legislation.
In some countries there seems to be an increasing tendency to regulate in more
and more detail the professional practice of nurses by laws and regulations. The
making of these regulations is often initiated by physicians and, more often than
not, supported by the nurses and their professional organizations.
However, it is known from experience that the more exhaustive and detailed
such regulations are made, the more problems seem to be created. As it is stated in
the aforementioned WHO report: "The definition of a nurse and the precise listing
of a nurse's duties and functions seem to be questions difficult to answer for law-
makers." The problems arise from the fact that there always will be patients for
whom the regulations don't fit and situations were the legal rules cannot be prac-
ticed. Another observation worth mentioning is that detailed lists of functions
which legally can be performed by nurses have a tendency to be very technical and
medically oriented, particularily when the purpose is to clarify which of the physi-
cian's activities a nurse can be allowed to execute. The care concept, which is the
fundamental aspect of nursing, is an activity standing on its own feet. In all societies
there are needs for nursing care which mayor may not be connected to medical
treatment.
In the future with increasing groups of elderly and handicapped persons and
with a complexity of problems, the service delivered should more often be based on
nursing judgment than on medical diagnosis.
This genuine concept of nursing may have difficulties to function and make
progress because technical procedures and tasks inherited from the medical profes-
sion dominate the legal rules. Thus the legislation can easily function as a constraint
for further development and be an obstacle for the nursing profession.
In the report from the second liaison meeting with nursing/midwifery associa-
tions on WHO's European Nursing/Midwifery Program the following remarks
exists: "The constraints placed on the development of nursing care services of high
quality ... by current legislation was a recurrent theme ...." And "legislation and/or
regulations regarding health services ... hamper the implemention of needed
change" [2].
In some countries very few regulations regarding the practice of the health pro-
fessions, in general, exist. There is, for instance, not even an attempt made to draw a
line between the duties and functions of a physician and those of a nurse. Neverthe-
less, in these countries fewer problems seem to exist regarding these questions than
100 I. H. Haugen
in countries with more detailed legal regulation. What is now said, however, does
not mean that legislation is not wanted or needed. A sound and appropriate nursing
legislation is both necessary and desired. In fact, it is a prerequisite for nursing
progress.
In the WHO report on legislation it is stated: "Very few countries in the WHO
indeed have consolidated nursing laws and rules. The numerous legislative refer-
ences demonstrate the need for regular consolidation of nursing legislation in the
European countries, and this would certainly be welcome on national and intema-
tionallevels." The legislation in this field seems to have developed rather casually,
and without a national policy to the question.
If you ask why one specific system for regulating nursing practice is preferred,
or to what extent, and why it is desirable to regulate health professionals practice by
law, your question may not be answered. This is why we need a broad discussion
about the principles on these questions.
Let us then look at some other steering mechanisms in the health field and sys-
tems regulating the practice of health workers. Apart from legislation, two main fac-
tors are working together in a steering system. The first one is the ethical standards
of the professions. The professional ethics include attitudes toward individuals,
such as confidence, respect, human consideration, compassion, and general atti-
tudes toward life. Due to traditibn, ethics is often connected with Christianity and
charity. Nurses in particular have in recent years, as part of the struggle for indepen-
dence, tried to distance themselves as a profession from religion, and therefore
meant that ethical rules should be embedded in, or replaced by, laws and regula-
tions.
Few other, if any, services are so dependent on ethical standards as the health
field, and the ethics of the nursing and medical professions are as old as the services
themselves.
Let us, as an illustration, concentrate on confidence and the influence of this
ethical concept in the health field. Confidence between the persons involved is es-
sential. It is an assumption that everybody can trust everyone: the observations are
correct, the information is exact, and the instructions are performed or forwarded.
Information is often given orally; this shows the extent of the confidence. With-
out trust as part of professional ethics, the health care system probably would col-
lapse.
Nurses and physicians traditionally have well-developed ethical standards.
Some of the ethical rules are now embedded in legislation. One example is pro-
fessional secrecy. Professional secrecy also exemplifics how legislation and ethical
rules can be in harmony, and not in conflict with each other.
However, just a few legal provisions exist on the ethics of the nursing profession.
The ethical standards are more often controlled by the profession itself, and the
professional organizations usually operate a consultative service for the member-
ship and the society. The organizations may also have the power to take disciplinary
actions, i. e., to exclude from membership those who break the ethical rules.
The other important factor in the steering system is the professional judgment of
the practitioners. Nursing and medical decisions made by nurses and physicians are
all of great importance to the patients. The basis for these decisions is professional
judgment, which again is built on knowledge and experience. From an ideal point
Law or Ethics: Which of Them Should Regulate Nursing Practice? 101
of view, such decisions should be taken solely to benefit the actual patient. In order
to do so, you have to have a flexible system for decision making, based on profes-
sional judgment and ethical rules.
Professional judgment and ethical rules are linked closely together. They very
often overlap each other and can sometimes hardly be separated. Together they
form what we call professional competence. The way we take care of a patient with a
decubitus ulcer will, for instance demonstrate them both: our professional judg-
ment in the choice of the method used, and our ethical standards expressed through
concern, attitude, and priority given to this patient.
In conclusion, in order to secure the patient's life and health the practice of
health personnel has to be regulated. Practice is regulated by law through a system
of licensing: those who possess the required qualifications are licensed. The possi-
bility of withdrawal of the license to practice in case of malpractice should be suffi-
cient for this purpose.
If professional judgment and ethic~l standards are good enough, laws and regu-
lations should just frame the basic principles and not be too detailed and specific.
Legislation and jurisprudence will never be a good alternative to professional
competence. Flexible legislation is also th~ best tool for improving nursing practice,
while too detailed provisions can lead to stagnation. In countries with a well-devel-
oped health care system and high ethical and professional standards of nursing ser-
vice, a legal frame for nursing practice which is broad enough for further develop-
ment should be preferred.
The question asked in our title was law or ethics: which of them should regulate
nursing practice? The answer, in short, is neither one nor the other exclusively. We
certainly need both law and ethics in nursing practice.
References
1. Report on a World Health Organization (WHO) study on Legislation concerning Nursing/Mid-

wifery services and Education, World Health Organization, Regional Office for Europe, Copen-
hagen 1981
2. Report on Second Liaison Meeting with Nursing/Midwifery Association on WHO's European
Nursing/Midwifery Programme, World Health Organization, Regional Office for Europe, Co-
penhagen 1976
Education
Should Nurses Study Ethics?

J. B. Thompson and H. O. Thompson
1 Introduction
For many people, the question of whether or not nurses should study ethics remains
open. One obvious evidence is that we do not yet have ethics taught in all schools of
nursing. Some teach it but it is not strongly emphasized. Some frankly say that the
answer to this question is no. The reason may be simply one of curriculum. The
schedule is already too crowded. With the knowledge explosion, there is already
more to teach than students can possibly have time to study.
Other negative responses turn on the belief that nurses do not make decisions:
they just follow orders. Even where there is a team approach to health care, the phy-
sician is often seen as, or claimed to be, the "captain of the ship."l We see this clear-
ly in the 1929 Catechism for Nurses quoted by Dr. Campbell with its rule for abso-
lute loyalty (read "obedience") to the physician.
This attitude was widespread in the pre-1940s. The Nuremberg and subsequent
trials of war criminals after World War fI often brought forth the defense that they
were only following orders. This defense was rejected. This excuse is no longer ac-
ceptable in our world. Nurses are no longer shielded by, nor can they hide behind,
the defense that they are only following orders. In some countries, the courts are
still in the pre-1940s, but they are beginning to catch up. Nurses are being held re-
sponsible and their responsibility is being recognized [1-3].
This situation is a mixed blessing. Some people do not want responsibility. Fol-
lowing Lowental's psychiatric perspective, we can note that in growing up, adults
take on responsibility (Chap. 5). The adolescent wants privileges without responsi-
bility. There's a sense in which nursing is still growing up or growing toward being a
profession. Nursing is and is not a profession. It is in the process of becoming a pro-
fession. What this means is that individual nurses stand on a spectrum. Many have
long since become professionals in the fullest sense of the word. Others are not, and
probably never will be, professionals, while others stand somewhere in between [4,
5].
There are those who say that nurses do not need to study ethics because, while
they do not officially make decisions, they can always get what they want through
covert decisions. It is simply a matter of not letting "daddy" know what is going on.
It is a pattern familiar to the dominated who quietly do what they have to or need to
1 This concept appears in a "Joint statement of practice relationships between obstetricians and gy-
necologists and certified nurse-midwives," where we find the words. "The maternity care team
should be directed by a qualified obstetrician/gynecologist."
104 J.B.Thompsonand H.O. Thompson
do without stirring up any fuss. One could suggest that this is in itself an ethical situ-
ation, or that for this very reason nurses most definitely should study ethics for they
are indeed making decisions.
Our answer to the title question is yes, nurses should study ethics. Part of this is
based on Jacques Barzun's suggestion that the very nature of human relationship is
moral [6]. This thought is echoed by Paul Ramsey as quoted by Sister Simone Roach
(Chap. 29). We would extend this to the nature of the human. Robinson Crusoe was
a moral being with or without Friday. There is no comment here on the content of
the moral. A moral or a person's morals may be good, bad, or indifferent. It is a
matter of the standard of judgment one might use. The point here is that to be hu-
man is to be moral. The amoral person is classified as a psychopath or sociopath.
Here, take note, we are not limiting ethics or morals in nursing to the making of de-
cisions, covert or overt. It is a matter of being. This "is + ness" might be considered
under what Anne Davis has called descriptive ethics, that which is (Chap. 12).2
In our work, we have found it useful to use the term morals as the shoulds or the
oughts oflife, what Davis has called normative ethics. This is Henry D.Aiken's level
two of moral discourse, as outlined by Sister Roach. Aiken's level three on ethical
principles comes close to our use of the term ethics. We see ethics as the philosophi-
cal question, "Why?" The ethical concern is to understand why we hold or practice
a given moral standard. Ethics is an effort to understand.
Nursing comes in here in its professional role. One could say that anyone could
be a nurse. We could take someone off the street and give him or her the task of
nursing. The contrast with the professional nurse, however, is profound. The profes-
sional nurse by contrast, knows what she/he is doing. This knowledge is not just a
memorized list of data, though it certainly includes data about health and illness
care. This knowledge is a much deeper kind of understanding. It is understanding
why (S. Pollock, personal communicationV
We note in passing that it is desirable to be able to articulate the why of ethics in
order to communicate it in a cognitive way. Davis noted the importance of this artic-
ulation and we agree. Murphy commented on the distinction between the cognitive
and the affective. The cognitive is crucial for communication and for the preserva-
tion of knowledge. But we would emphasize here that understanding involves both
the affective and cognitive [13].4 In the deepest sense, the one who understands
knows what she/he is doing. The ethical why involves this level of understanding.
It is in this sense that we agree with the aphorism that "to be professional is to be
ethical: to be unprofessional is to be unethical" (D.G.Jones, personal communica-
tion).5
2 Structural ethics talks about the deep structures with which we are born. The concept of the good
and the innate feeling that we must obey moral codes are examples of deep structures. See George
H. Kieffer [7], George E. Pugh [8], Gunther S. Stent [9]. The work of Lawrence Kohlberg [10] is pro-
minent in this concern. See also Brenda Mundsey [11] and Lande and Slade [12]
3 Dr. Solomon Pollock, University of Pennsylvania, once distinguished between a technician and a
professional. The technician knows what he/she is doing. The professional understands why
4 She notes that if we did not have some interest, some sense of value, i.e., affective concern, we sim-
ply would not bother with the cognitive
5 Dr. Donald G.Jones, Drew University, noted this in the area of business ethics. It has wide-ranging
implications for all professionals .
Should Nurses Study Ethics? 105
Take note once again that this does not tell us about the content of the ethical.
To be sure, to understand is also to know in the traditional sense. Nurses should
study ethics and in that study is included the various approaches to ethics and the
nature of ethics. Nurses need a working knowledge of deontology (rules), utilitarian
or teleological (ends) ethics, the philosophical approach in general, the theological
approach, natural law, the social science approaches of psychology or sociology or
anthropology. That is another paper, however. Here we tum to the teaching of eth-
ics. If nurses should study ethics, how do we teach ethics?
2 Teaching Strategies in Ethics
When one begins to think about how to teach ethics for nurses and other health pro-
fessionals, one considers the objectives and resultant content, the expertise of the
faculty, the nature of the audience (level and type of student), and the amount of
time that is available for the teaching/learning efforts. Each of these factors will de-
termine the what, who, and how ethics in nursing is taught. In the next few para-
graphs, We would like to offer some examples of each of these factors in the teach-
ing of bioethics from our experience during the past 7 years of team teaching with
nurses, medical students, and other heal~h-related professionals.
2.1 Purpose and Objectives
The overall purpose of teaching ethics for nurses will determine the objectives one
uses for content. There are at least three major purposes of ethics teaching in nurs-
ing: (a) to prepare a nurse-ethicist; (b) to prepare students in nursing formally to un-
derstand what is ethics, what are the ethical dimensions of practice, and how does
one make ethical decisions in practice; and (c) to sensitize nurses (short-term basis)
to the topic of ethics and ethical decision making in practice, education, and admin-
istration.
The first purpose, that of preparing a nurse-ethicist, involves long-term study,
such as a doctoral program or post-doctoral fellowship (e.g., Kennedy scholars).
We will not discuss this level of preparation in this paper. The majority of our team-
teaching efforts have dealt with formal courses in ethics (the second purpose) and
short-term sensitization (the third purpose) efforts in the classroom with a variety of
learners. The major objectives we use for formal as well as continuing education ef-
forts include the following:
1. Define and discuss common ethical theories as applied to decisions about
health/illness care
2. Define and discuss ethical principles of autonomy, informed consent, benefi-
cence, nonmaleficence, justice, truth-telling, and the concepts of allocation of re-
sources and professional accountability
3. Define and discuss values and values clarification
4. Identify and use a reasoned decision-making process in examining actual case
studies in medical and nursing practice
106 J.B.Thompson and H.O. Thompson
2.2 Content and Methods
Given the objectives chosen for teaching ethics, one then needs to formulate the ac-
tual content to be included and how that content will be taught and learned. We
have successfully divided the time alloted for teaching between formal lecture and
practical case analysis in small groups. Here are some examples from our teaching
experiences.
One semester we taught an interdisciplinary course (14weeks) in ethics, law,
biomedical technology, and health/illness care. The faculty consisted of a lawyer, a
biomedical engineer, an ethicist, and a health professional. We took the first four
class periods of 3 hours each for each faculty member to provide the theoretical ba-
sis for the course in his particular field of expertise. The rest of the class consisted of
having small groups of ten students each work 1-1.5 hours with a specific case and
guidelines for discussion, and then return to the large classroom to share the results
of their discussion with the total group. This way we could cover many different
cases during the semester, and the total group could benefit from the deliberations
of the small groups. Faculty also participated in small groups on a consultation ba-
sjs and also within the large discussion class. Since we have found that role mod-
eling is an essential teaching method, the faculty acted as a panel and presented,
discussed, and analyzed a case in front of the class during the fifth class period be-
fore the students began their small group work the next week.
The small groups were given cases reflecting practice situations and illustrating
the ethical issues of autonomy, informed consent, allocation of resources, and ac-
countability. We recognize that moral reasoning (reasoned decision making) is es-
sential to our teaching efforts and therefore provided guidelines for analyzing the
case studies based on Rebecca Bergman's decision-making model and further de-
veloped by us. These guidelines, which appear in full in our text [2], consider the fol-
lowing areas of analysis. First the learners are asked to review the case; determine
who the players are and what decisions need to be made; determine what ethical is-
sues are involved and the historical, philosophical, and religious bases for each; de-
termine who should make the decisions (who owns it?); examine what the leN and
ANA codes for nurses might say regarding the actions needed of nurses; decide on
a plan of action with reasons for the decisions; determine alternative plans/deci-
sions that could be made and their potential implications for all concerned; and
share ideas on action with all group members [11, 15,2 pp 11-12].
Another example of a formal course in ethics involves joint medical-nursing stu-
dent education at the University of Pennsylvania. We are proposing a course which
will begin with formal presentations on ethics, theories, professional roles, rights
and responsibilities, reasoned decision making, and collaborative efforts in health/
illness care. This formal content will then be followed with biweekly grand rounds
with students and faculty exploring a different case study each time. We propose to
expand the decision-making team to include other health professionals and family
members, as indicated, and to offer students time to explore how they make deci-
sions in care and, more importantly, why they choose a particular decision in the
given situation.
Our teaching efforts with short-term groups have varied in time from 1 hour to 8.
We use seminar format, lecture/discussion, workshops, rounds, and lately involve-
Should Nurses Study Ethics? 107
ment in medical student's Journal Club as the methods of instruction. The content
outline remains the same, but the depth of presentation and time for small group
work varies with the overall time assigned for the presentation.
2.3 The Faculty
The success of our teaching efforts in ethics is directly related to the nature and
background of the two of us. H. Thompson provides the needed expertise in philos-
ophy, history, religion, and ethics, while J. Thompson provides the needed expertise
in nursing and practice issues. Though each of us could teach alone after 7 years of
joint teaching, we think the students receive much more than two when we work to-
gether. As mentioned earlier, role modeling is very important in this difficult, yet
callenging and necessary, field of study. We model for our students role definition
and collaboration and put into practice the collaborative sharing of ideas and deci-
sions (even when we don't always agree). This team effort was enhanced even more
when we added a lawyer and biomedical engineer to our teaching efforts in ethics.
The faculty concluded that they learned as much as (and possibly more than) the
students in this class. The students supported the value of faculty willingness to
openly present their individual ideas ana value positions while also working to-
wards understanding those who differed in views and orientation on crucial ethical
issues.
3 Summary
In summary, we are pleased with the response of nurses and other health profes-
sionals to the learning of ethics in their practice arena. We think much of the success
of our particular efforts is related to the small group discussions and application of
decision making to actual practice situations. We try to present everyday nursing di-
lemmas for study rather than focus on the widely publicized cases such as Quinlan
or the starvation of neonates. Students learn to trust and accept each other as col-
leagues while sharing their own beliefs/values on particular topics. They learn to
work together to resolve ethical dilemmas or to be comfortable while retaining their
separate positions. This of course can be done in a classroom more easily than in a
work setting. But it is important to have students and nurses realize that decisions
may not always reflect their own personal judgment of what should be done in a
given situation. They, and we, need to understand the traditions of others as well as
our own.
We enjoy our teaching efforts and encourage others to continue their efforts or
to begin new ones in the field of ethics in nursing. It is challenging, interesting, and
sometimes difficult to teach in this field, but it is very necessary and important for
the future of our practice and the health and welfare of our patients.
108 J.B.ThompsonandH.O. Thompson
References
1. Young Kelly L (1980) Dimensions of professional nursing, 4th edn Macmillan, New York
2. Thompson JB, Thompson HO (1980) Ethics in Nursing. Macmillan, New York
3. Fiesta I (1983) The law and liability: A guide for nurses. Wiley, New York
4. Camenisch PF (1975) On the professions. Hastings Center Rep (HCR) 6/5: 8-9
5. Friedson E (1978) The perils of professionalism. HCR 8/3: 47-49
6. The profession under siege. (1978) Harpers Mag 257/1541: 61-68
7. Kieffer GH (1979) Bioethics: a textbook of issues. Addison-Wesley, Reading p 29
8. Pugh E (1976) Human values free will, and the conscious mind. Zygon 1111: 2-24
9. Stent S (1976) The poverty of scientism and the promise of structuralist ethics. HCR 6/6: 32-40
10. Kohlberg (1981) Essays of moral development Harper & Row, New York
11. Mundsey (ed)(1980) Moral development, moral education, and Kohlberg. Religious Education
Press, Birmingham, AL
12. Lande N, Slade A (1979) Stages. Harper & Row, New York
13. Midgley M (1981) Heart and mind: the varieties of moral experience. St. Martin's, New York
14. Code for Nurses with Interpretive Statements (1976) American Nurses Association, Kansas
City (Encyclopedia of Bioethics), vol 4, Free Press reprint, New York, pp 1789-1799, 1978
15. Tate BL (ed) (1977) The nurse's dilemma, International Council of Nurses, Geneva
The Work Environment as a Factor in Continous Ethical Training
C.Sus
1 Introduction
After some decades during which diverse extra-university influences have provoked
the elimination of ethics from the study programs of the college of medicine and the
school of nursing, we find ourselves, almost everywhere, in the explosion of medical
ethics. Never, as far as I know, has so much been written, taught, or discussed as at
present about the demands of ethics and deontology in the leading countries in
medical science. A certain idea is extending itself and taking hold: those professions
related to health have by their very nature a moral obligation. For this reason it is
indispensable that the doctor as well as the nurse should know how to rationally
support the ethical dimension of their decisions. And this occurs to the extent that,
for example, Herranz [1] has been able to affirm: "To speak of ethics in medicine is
a redundancy, since any Medical practice or clinic, which is not ethical, would be
neither a clinic nor a medical practicet The ethical dimension of our occupation
coincides with the spirit of the Universities, the scientific societies, or the profes-
sional organizations, and it is nowadays a topic of common interest, which is made
evident each day through the newspapers and television and which demands logical
and reasoned answers to the problems that are raised relating to health. Because of
this, it is not surprising that, as Herranz [1] has also said, "Medical ethics is one of
the few and fortunate disciplines that can, in the United States during a time of
economic recession, not only maintain itself but even expand its research pro-
grams." And such is, of course, the case of my university.
The University of Navarra was founded in 1952, and began its programs in med-
icine and nursing a few years later, and complementing them some time later with a
University Clinic that annually attends to 65800 outpatients and 12000 inpatients;
it has 500 beds and employs 1000 professionals and staff. The preoccupation for
ethics in the clinic, as well as in the college of medicine and the school of nursing, is
a natural consequence of the principles that govern all our university work. In each
of us, the words pronounced a long time ago concerning this by the founder of the
university, Monsignor Escriva de Balaguer [2], are ever present:
The traits that characterize this university can be summed up as follows: educa-
tion with personal freedom and also personal responsibility. As with freedom
and responsibility one works at will, yielding the maximum where there is no
need for control or vigilance, because since everyone feels at home all that is
needed is a mere timetable. Later, the spirit of living together is generated, with-
out discrimination of any type. It is in living together that a person is formed:
where each one learns that in order to be able to demand that others respect your
freedom, one must know how to respect the freedom of others. Finally, there is
the spirit of human fraternity: the individual talent of each one must be put to the
service ofthe rest; if not, their service is limited.
110 C.Sus
For us, it is an indisputable principle that the object of nursing is the care of human
beings: we believe that this fact can never be forgotten or else nursing would lose its
fundamental characteristics. This should not be forgotten, not even when the nurse
perceives that the patient views her only as a "maintenance technician" of the com-
plex machinery which is the human organism and does not expect or demand more
from her. The nurse should never make a game out of this attitude and regard the
patient as just a simple damaged biological mechanism. Why not? Purely and sim-
ply because it is not so. Man is someone so valuable that it proves entirely incom-
patible with his dignity to forget this while attending to him. Naturally this assertion
involves a determined anthropological conception, to the effect that a human being
is a creature of God with a trascendent destiny; because if, on the contrary, I be-
lieved that man were only an immanent biological machine, I would lack the moral
strength to affirm the doctrine that I have indeed pointed out. I think. that any ma-
terialist could argue that this conception of man is not universally shared. This may
be so. But man is "what he is," and not "what each one thinks he is"; and if one suc-
ceeds in getting to know him, the objective demands deduced from the concept will
contribute, if they are respected, to the perfection of man himself. If, on the con-
tr.ary, anyone does succeed in this antropologic experiment, we will inevitably de-
stroy man, no matter how good our intentions are.
This callenge of nature to thinking man is of fundamental importance. In matters
of such depth it would be gravely irresponsible to adopt positions that reverberated
unfavorably in the treatment of the patients invoking as an alibi: "The matter is de-
batable and is being debated." To the question: "And what if man is nothing more
than a piece of matter, who does not need any special consideration?" we can at
least again ask "and what if he is more". The answer is simple: "If he is more and
we have ignored it in practice, we have not practiced nursing, but something else
which, at the most, may resemble it in some peculiar way."
2 Personnel Selection and Formation
It is not strange, considering what has been said, that we have carefully chosen the
personnel which are to work in the University Clinic. The fundamental criteria of
this selection can be summed up as follows:
1. It is necessary to have clear the idea just recently exposed, namely; that nursing
has as its object human beings, who must be treated as such, which would be
practically impossible if the nursing professionals were not aware of the magni-
tude, transcendency, and richness of what they have at hand
2. The determination to continually improve, onself, as much in one's technical ap-
titudes as in one's attitudes towards colleagues and - most of all - towards the
patients
3. The temperamental characteristics necessary for the practice of this profession,
among which we could emphasize: comprehension, strength, sensitivity towards
personal and social problems of others, and a sense of responsibility
The selection is only the beginning of an educational process that lasts all of the
professional life. It is useful to emphasize that this educational process has two di-
The Work Environment as a Factor in Continous Ethical Training 111
mensions that require very different treatments: technical training and the already
mentioned improvement of attitudes. Anyone who shows just a little interest in edu-
cational problems knows that techniques can be learned, whereas attitude improve-
ment is fundamentally the result of an impregnation process in an environment in
which such attitudes constitute the basic framework of ordinary activity. Stated in
another way: we consider that it would be useless to make any attempt to school
nurses in respect to their attitudes if the preoccupation of the clinical institution
were not very intense in making real, through our daily work:, the type of interper-
sonal relations that are considered ideal.
I am quite aware that such a way of thinking implies costly demands; but I am
convinced that the clinical institutions, as well as individuals, feel the same way as
Sheed who rightly said that if someone does not make a persevering effort to attain
goals that at first seem unattainable - and that, surely, are for the most part - one
deteriorates irremediably.
For this reason, I wanted to address the subject of the work environment as a
factor in continuous ethical training. Without this environment, the education
would be incomplete. On the other hand, the environment in question is the result
of the determination and the attitude of everyone, and not simply a topic or a sum
of topics from the curriculum.
The space limit obliges me to make reference solely to the characteristics of the
environment which we in the clinic believe to be fundamental. They are the follow-
ing:
1. Delicate sensitivity in the treatment of patients. The present-day despisement for

the forms of treatment brings about a risk of internal insensitivity that is easily
translated into forgetting that each sick person requires an extraordinarily careful
individual attention. As Andre Piettre [3] said, "sooner or later, vulgar behavior
makes the heart vulgar."
2. Comprehension, that is the ability to put oneself in the patient's place, to pentrate
his soul, to feel with him, to encompass each and every one of his possible reac-
tions, not to label him
3. Discretion that consists in knowing when to speak and when not to speak, know-
ing how to say what must be said and to omit what is prudent to be omitted. This
type of discretion must always be exercised and be used in relation to everyone:
the patient, his family, etc.
4. Humility when things go well and also humility when they go badly, to accept our
own responsibility and our failure without blaming others, or disclaiming the
blame
5. Compassion that does not consist solely of someone's capacity for tenderness,
but above all someone's "feeling with," and making this compatible with the ap-
plication of the appropriate professional cures
6. Personalization in the treatment of the patient. In the University Clinic no one is
merely a number. The patient is always called by his name. They are people that
are happy to see how their individuality - and their intimacy - is respected even
112 C.Sus
while doing physical explorations, transferring them to the operating room or

bathroom, etc., not only because they are wearing clothes which do not hinder
the perfect realization of the techniques, but also because they are always accom-
panied by a nurse.
7. Care of details. All of us who work in the clinic have a reason to be proud of the
impact that the care of details produces in the visitors: the cleanliness, the work
environment, the friendliness, the seriousness, etc. And I want to point out here
how tremendously and positively the external aspect of the professionals who
work in the clinic calls the attention: I can assure you from my experience that
the fact that everyone wears the uniform of their respective profession helps
everyone in adopting internally the sum of attitudes that are so positive in the
treatment of patients.
8. Individualized attention to the professionals. Since, as I have said at the begin-
ning, the improvement of attitudes of professionals is an individual and perma-
. nent process, the clinic also pays individual and permanent attention to each one
of its nurses.
In a first phase, when someone is incorporated into the clinic, in order to help him
or her integrate as soon as possible into the group, among other things it is required
that the institution's objectives be clarified, that different paths be opened to them
according to each one's peculiar way of being, that they be stimulated and that their
initiative be awoken so that they do not act as well-programmed robots that obey
orders and nothing else, but that they be oriented toward the execution of adopted
decisions, etc.
After this initial and intensive attention there follows a stimulation towards con-
tinuous perfectioning. This goes far beyond the actualization in the knowledge of
techniques: it insists repeatedly in the right formation of the professional con-
science based on respect for the person, on the obligation to execute intelligently
and loyally the orders of the doctor, on the obligation to renounce acting according
to nonethical procedures, on the necessity of extending to the utmost good educa-
tion and attention to details, on the necessity to recognize that in every organization
a leader is necessary to direct, on the essentialness of discipline based on justice and
impartiality, and - at last - on the importance of a climate of confidence for the effi-
cient practice of teamwork and for an improvement in the attention to the patients.
3 Organization of the Nursing Headquarters
To achieve the environment which I have just described, the nursing headquarters
has adopted an organization of which we could emphasize the following:
1. It is formed by the head nurse and three general supervisors, two in the hospitali-
zation area and one in the polyclinic area.
2. It has the efficient help of the supervisors and instructors of the various services
and nursing units, to whom they delegate the organization of work of the gradu-
The Work Environment as a Factor in Continous Ethical Training 113
ates, the experience of the students, the organization of shifts, everything relative
to holidays and leaves, etc. The nurses headquarters receives weekly information
about all of this and in the respective reunions with all supervisors and instruc-
tors, instructs them on the directives and objectives which they must transmit to
all of the personnel.
3. The nursing department, which is directed by the nursing headquarters, has been
assigned all of the tasks relative to the care of patients. It cooperates with the ad-
ministrative council of the clinic on three fundamental points:
(a) The determination of the objectives of the center precisely with regard to the
attention given to the patients
(b) The assumption of competences such as the selection of the personnel to be
dedicated to the attention and care of patients, the elaboration of its work
force, the scheduling of conventions and perfection courses, the continuous
evaluation of the nursing personnel, etc.
(c) The active presence in advisory organizations of the administrative council: in
effect, members of the Headquarters and, by their delegation, supervisors,
form part within the University Clinic of different commissions, boards, and
committees such as those of Investigation, Hygiene, Hospitals, Pharmaco-
logical Clinic, Laboratories, Charts Clinic, etc.
4. It is a constant preoccupation of the nursing headquarters that all personnel un-

der its supervision continuously follow up their studies, show an interest in inves-
tigation, are up to date on the new discoveries in medicine that directly affect
nursing, and that they put special emphasis in everything that they do, as much as
it is possible, within the frame of teamwork.
5. Nursing headquarters takes care of orienting its personnel so that, according to

their individual preferences and aptitudes, they specialize in the different areas of
nursing from the choices that the clinic up to now permits: cardiology, orthopedic
surgery, physical therapy, Laboratory, internal medicine, matron, pediatrics, psy-
chiatry, operating room, intensive care unit.
6. During the year, the nursing headquarters programs and develops interdiscipli-
nary courses and seminars in which Supervisors and instructors, graduates, and
professors of different colleges participate: medicine, pharmacy, biology, philos-
ophy, theology, etc. It also promotes the execution and publication of scientific
works and the presentation of works and communications at national and inter-
national conventions.
7. Nursing headquarters pays special attention to its relations with the University
School of Nursing, so that the practical teaching of the nurses is adjusted to an
identical criteria, and in order that the knowledge acquired in the classroom is
reinforced through its practical application. The reports of the supervisors and in-
structors and those of the heads of the different services to which the future
nurses will rotate are fundamental for the University School of Nursing, at the
time of the student evaluations.
114 C.Sus
4 Conclusions
Newman [4] said that the university is an "educational environment." A clinic, in or-
der to be called a university, must also be "educational." But its possibilities with re-
spect to this substantially depend upon the environment that the clinic is capable of
producing. If it is appropriate, the real-life situations that the nurse finds daily in
her work with patients will be decisive in her training and in her constant improve-
ment. The spirit of the University of Navarra impregnates its University Clinic and
emphasizes the Christian sense of life and, as I said at the beginning, its love of free-
dom and responsibility, and because of this emphasis, each and every one of the en-
vironmental characteristics which I have referred to here. I can assure you that this
environment is a decisive factor in the continuous ethical training of our personnel
as the accumulated results of over 30 years show.
References
1. Herranz G (1982) "La Etica medica i, una disciplina dispensable? Rev Med Univ Navarra 63: 267
2. Escriva de Balager 1M (1980) Conversaciones con Monsefior Escriva de Balaguer. Rialp, Madrid
3. Pietre A (1977) Carta a los Revolucicmarios Biempensantes. Rialp, Madrid
4. Newman J (1950) La 1nvestigaci6n y los fines de la Universidad (edited by Sanchez Agesta).
Arbor 50: 193
Research
Aspects of Ethics in Nursing Research

R.Bergman
1 Introduction
Ethics and research are both areas of major concern to nursing. They are the moral
and knowledge threads that are interwoven into the fabric of nursing. Ethical be-
havior - the "right" and "wrong" of professional and personal decision making and
action - is to a large extent dependent on available scientific knowledge. Research,
a major tool for obtaining this knowledge, must itself be guided by ethical stan-
dards. This paper will share with you reflections on the ethics of nursing research
and will relate to three subtopics:
1. research involving human subjects: declarations, codes, and laws;
2. research that does not involve human subjects; and
3. omissions in nursing research as an abrogation of ethics.
2 Research with Human Subjects: Declarations, Codes and Laws
International declarations, although not binding by law, have considerable moral

force. The Geneva Convention (1864) protects the rights of prisoners and detainees.
United Nations declarations, such as the Declaration of Human Rights (1948) and
Rights of the Child (1950), deal with human welfare in the broadest sense. The
American Hospital Association's Patient's Bill of Rights (1973) is concerned with a
specific population. The objektive of all of these is to protect human beings from
abuse or harm and to promote their maximum welfare.
Some documents relate specifically to research. Following the Nuremberg med-
ical trials which revealed the inhuman acts committed by the Nazis in the name of
science, the Nuremberg Code (1946) established ten principles of medical research.
They are given in abbreviated form below.
1. Voluntary consent of the human subject (informed consent) is essential.

2. The experiment is designed to yield fruitful results for the good of society, not
procurable by other means.
3. Human experimentation is based on results of animal experimentation.
4. The experiment avoids all unnecessary physical and mental harm.
5. There is no reason to believe that death or disability will result.
6. The degree of risk must never exceed the humanitarian importance of the prob-
lem.
116 R. Bergman
7. All precautions must be taken to prevent any remote possibility of death or inju-
ry.
8. The experiment must be conducted by scientifically qualified persons.
9. The human subject can withdraw at any point.
10. The scientist will discontinue the experiment if continuation is harmful.
The Helsinki Declaration, adopted by the World Medical Association in 1964, dis-
tinguishes between therapeutic and nontherapeutic research. It has become the ba-
sis for national laws and professional research codes. In a case which reached the
Supreme Court in Israel in January 1982 permission was refused to treat a terminal
cancer patient with an untested drug. The Helsinki Declaration was the main source
for the decision.
Additional sources of moral guidance for researchers are professional codes. The
Hippocratic Oath (4th century B. C.) required "absolute respect for the sick" and
"for human life."
The Florence Nightingale Pledge (1893) required that "I will abstain from what-
ever is deleterious and mischievous" and "will devote myself to the welfare of those
committed to my care."
The International Council of Nurses (lCN) Codefor Nurses (1973) requires that
"nurses take appropriate action'to safeguard the individual when his care is en-
dangered by a co-worker or any other person." The ICN statement on nursing re-
search (1977) states that "research should comply with accepted ethical standards."
Several nursing associations have published specific ethical codes for nursing re-
search. Seven points from the United Kingdom Royal College of Nursing code in
1977 [4] relate to the personal responsibility of the nurse researcher.
1. The researcher is responsible for obtaining freely given and informed consent
from each individual who is to be a subject of study or personally involved in a
study. The researcher should explain as fully as possible and in terms meaningful
to the subjects what the research is about, who is undertaking and financing it,
and why it is being undertaken. She/he must make explicit the subject's right to
refuse to participate or to withdraw at any stage of the project, and this right must
be respected.
2. If the subject for any reason is unable to appreciate the implications of participa-
tion, informed consent must be obtained from relatives or legal guardian.
3. If the subject is a patient the researcher should discuss the proposed research
with the patient's doctor or the appropriate medical officer.
4. If the nature of the research is such that fully informing subjects before the study
would invalidate results, then whatever explanation is possible should be given to
the subject. There must be provision for appropriate explanation to the subject
on completion of the study.
5. Explanation to the subjects should include information as to how their names
came to the knowledge of the researcher. She/he should identify herself/himself
and the organization responsible for the study and leave with the subject a note
giving this information together with a brief statement concerning the nature of
the study.
Aspects of Ethics in Nursing Research 117
6. Research subjects must be assured protection against physical, mental, emotion-

al, or social injury. No harm must come to them as a result of being involved in
the study insofar as the present state of knowledge allows.
7. The nature of any promise of confidentiality or restriction on the use of informa-

tion must be made clear to the subjects and adhered to.
The American Nurses Association "reaffirmed the profession's obligation to sup-

port the advancement of scientific knowledge" in its document "Human Rights
Guidelines for Nurses in Clinical and Other Research" (1975). It spells out the sub-
ject's right to freedom from intrinsic risk of injury, protection of privacy, and digni-
ty. It provides protocols to assure that these rights are carried out by the investigator
and the agency. Similar statements were published by the Canadian Nurses' Asso-
ciation (in 1972) and the New Zealand Nurses Association (in 1977).
Laws dealing with ethics of research are found in some countries. Nurse prac-
tice acts may limit nursing research and protect human subjects in broad terms -
such as limiting nursing interventions and requiring appropriate levels of education
for professional practice. Laws on research for citizens also bind nurses. For exam-
ple, in the United States, the 1962 Kefiuver-Harris amendment requires informed
consent of the human subject. Since 1974 all research funded by the U.S. Depart-
ment of Health and Human Welfare must be approved by an institutional review
board.
3 Research Which Does Not Involve Human Subjects
There is much important research in nursing which does not directly involve human
subjects. In such studies the res~archer is freed from considerable limitations but
still must demonstrate stringent ethical behavior in terms of validity and reliability
of data, objectivity in analysis, and responsibility for dissemination of findings.
These studies may examine materials, the physical environment, or records.
Example of studies with materials or the environment are: measuring the con-
tamination of air or objects in a specific area, such as a recovery room; comparing
the effectiveness of different agents to reduce malodors; measuring the strain to
which equipment, such as patient supports, can be safely subjected.
Examples of research utilizing records are: examination of number and kinds of
patient visits to a nursing clinic, comparison of agency policies, study of trends in
registration in educational programs, studies of child development.
Studies that deal with records that may identify specific groups or individuals
are audits of nursing records, evaluation of quality of care in a patient unit, review
of reasons for attrition in a small agency, or a study of staff activity. Some of these
studies may also utilize observation and/or interview in addition to records. In such
cases, although there is no physical harm to the persons concerned, there is an ele-
ment of intrusion of privacy and possible anxiety caused to the subject or agency,
and therefore appropriate protection of the individual and agency must be assured.
118 R. Bergman
4 Omission
The last area that I wish to discuss is that of omission - or "non-doing" - in nursing
research. I would call this "passive nonethical behavior." Seven kinds of omissions
are:
1. Inadequate response of researchers to suggestions from practitioners
2. Nonreferral of problems by practitioners to researchers
3. Refusal to allow access to the field
4. Unread research
5. Lack of application of reliable research findings
6. Unused nursing research skills and resources
7. "Giving up" desired research
I would like now to elaborate on these seven points
4.1 Inadequate Response of Researchers to Practitioners
the researcher may not seek out'or respond to suggestions from the field. She may
feel that she does not need this input, as her work will be based on previous research
and theories. She may see her own experience as sufficient to know what is going
on. She may consider the practitioner's perception as biased and/or limited and her
own as more objective and comprehensive. In some instances, because of an ex-
tended separation from practice, the researcher may feel threatened by dialogue
with a person who is exposed daily to direct nursing care.
Another reason for lack of sensitivity to the practitioner may be a gap in con-
ceptual or terminological communication. In a study on the nutrition of geriatric
patients, the charge nurse of the ward was concerned about the mechanics of pat-
ient feeding; the nurse researcher responded in terms of self-image, locus of control,
and principles of energy conservation.
4.2 Lack of Referral of Problems by Practitioner
The practitioner may passively impede research by not recognizing questions aris-
ing from her work. If she is aware of the need for study, she may not be ready to
pass on her ideas to the researcher because of previous rejection, shyness, or lack of
self-confidence. Some practitioners may wish to pass on their ideas but not know
how or to whom to bring their suggestions.
4.3 Refusal to Allow Access to the Field
Nurses in various levels of service or education may actively impede nursing re-
search by refusing access to the field. Refusal may come from the administration
level if the research is viewed as a burden on subjects or staff. There may be some
insecurity or fear of what the findings will reveal. A study on nursing staff satisfac-
tion in a large hospital was held up by the nursing office. They were aware of con-
siderable dissatisfaction and had developed a plan to counteract it. They stated that
a study on the subject would interfere with the planned program. In a nurses' activi-
ty study the staff objected to the presence of observers in the unit. They were afraid
that the "outsiders" would impinge on the patient's privacy and would be stressful
for the care givers. Interviews of both staff and administration in a study of the role
of the unit head nurse met with some antagonism because it took time in an over-
loaded workday.
4.4 Unread Research
A further and very common omission is not reading research. The blame, if it can be
so termed, may stem from several sources: the nursing education system that does
not sufficiently develop the desire and skills needed in order to comprehend re-
search; the nurses themselves, who are not sufficiently motivated to obtain and read
the research journals; the authors who write for their research peers rather than for
practitioners; the professional journals that require "sophisticated" reporting; and
the universities that demand "scholarly" publications of their faculties.
4.5 Lack ofApplication
Even when research is read, understood, and found relevant to the individual
nurse's area of work, findings are often not utilized. The introduction of change,
based on research, usually requires team decisions and administrative approval.
The concept of omission in utilization in this paper refers to ignoring findings or not
taking steps to forward their implementation in practice by all levels concerned with
practice. The many studies on reliability of methods of measuring patients' temper-
atures are crystal clear and have appeared in popular professional publications, yet
little has been done to change entrenched routines. The opposite side of the coin is a
commission: application of research without first ascertaining that the findings are
reliable and valid for the specific situation.
4.6 Unused Nursing Research Skills and Resources
Another omission is nurses who have the skills and opportunity and do not partici-
pate in research. There are a multitude of identified questions for which partial
answers could be found if nurses incorporated mini-research as part of their prac-
tice. We can learn much from systematic observations, questioning, recording, and
120 R. Bergman
analysis. Reasons for attrition from educational programs or employment can be

learned by interviewing each leaver, and their supervisors, using appropriate tools.
Recording by night nurses of reasons/situations which disturb patients' sleep can
provide data which may lead to the introduction of measures for promoting rest;
observing patient responses to these interventions could be a follow-up study.
Nurses with more advanced preparation in research methodology should design
and carry out more sophisticated studies. On-the-job research is dependent on the
readiness of the nurse to do studies and an the administration to recognize its im-
portance and provide logistic support.
4.7 "Giving Up" Desired Research
The final omission presented in this paper is giving up a project which the research-
er believes is important. All too often doctoral or masters students put aside a re-
search question that they really want to work on because their teachers are not inter-
ested in the subject. The growing emphasis on theory-based research has influenced
students and faculty to identify a theory and then fmd a related question rather than
look for theories that can help them understand or fmd answers to the questions
that "tum them on." Research instruments today need to be tested for validity and
reliability, and rather than develop and test a simple tool, we often find researchers
duplicating studies of little interest to them or seeking a study to build around ac-
cepted instruments. This dependence on established theories and tools may curb
original thinking and movement into new areas of investigation. This omission is
predominantly found among those people who are best equipped to do original re-
search and who have available research resources.
The 1977 statement on nursing research of the International Council of Nurses
(ICN) states "different levels of sophisticiation should be utilized,...should comply
with ethical standards,...[and] findings should be widely disseminated and their uti-
lization and implementation encouraged when appropriate." This broad statement
should encourage nurses to correct omissions if they are partner to them.
5 Conclusion
This paper briefly dealt with declarations, codes, and laws related to ethical aspects
of nursing research which involves human subjects, with ethical responsibilities in
research that do not present a danger to humans, and with ethical omissions in nurs-
ing research. The ICN Code for Nurses (1973) requires that we safeguard the indi-
vidual from harm, develop a core of professional knowledge, implement desirable
standards of nursing education, and take personal responsibility for nursing prac-
tice and continualleaming. Nursing research, conducted in an ethical manner, will
do much to forward these commitments.
References
1. Tate BL (1977) The nurses dilemma: ethical considerations in nursing practice, International
Council of Nurses, Geneve
2. Davis AJ, Aroskar MA (1978) Ethical dilemmas and Nursing Practice, Appleton-Century-Crofts,
New York
3. Fromer MJ (1981) Ethical issues in health care, Mosby, St.Louis
4. Royal College of Nursing of the United Kingdom (1977) Ethics related to research in nursing,
Royal College of Nursing, London
5. Human rights guidelines for nurses in clinical and other research (1975) American Nurses Asso-
ciation
The Ethics in Nursing Research
L.Hockey
1 Introduction
I derme nursing research as "research into those aspects of health care which are the
predominant and appropriate concern and responsibility of nurses." it must be im-
mediately obvious that this is neither an objectively derived nor a static definition.
What is considered to be the appropriate and predominant responsibility of
nurses is determined by many factors; there are tremendous variations among
countries, cultures, different care agencies within anyone country, and different
professional groups. There are also continuous and important changes over time.
My definition of nursing research is intended to be responsive to such variations
and changes.
In discussing the ethical issues of nursing research, it is important, therefore, to
be aware of the context and the background against which the research is conduct-
ed.
An issue is a point worthy of debate because it is important and because it is
viewed in different, often even in opposing, ways. An issue raises questions; it does
not answer them. An ethical issue implies choices in relation to human conduct. An
ethical issue or problem, according to Curtin and Aaherty [1], has three characteris-
tics:
1. It does not fall strictly within anyone or all of the sciences.
2. It is inherently perplexing and
3. the answer reached will have profound relevance for several areas of human con-
cern.
Ethical issues of nursing research raise questions about whether this activity should
be conducted or not. Is it right, is it good, ought we to do it, etc.? These are ques-
tions which imply a moral judgment.
I would like to deal with my topic from three perspectives:
1. The macroperspective; this implies a consideration of choices which confront
government departments and regional authorities charged with the responsibility
of providing health services in committing resources.
2. The macro/micro perspective; this implies a consideration of choices which the
nursing profession has to make in its commitment in relation to research involve-
ment.
3. The micro perspective: this implies a consideration of choices which an individu-
al nurse has to make in relation to research involvement.
The Ethics in Nursing Research 123
2 The Macro Perspective
Resource allocation on a national and regional basis is determined by political and

economic considerations as well as moral ones; all of these are interrelated. If an
activity is valued, money is more likely to be found for it; if an activity appeals to
public opinion, money is more likely to be made available for it. At times of serious
economic cuts, it may not be possible to find money for anything which is not con-
sidered urgent.
However, whether an activity is valued, whether it appeals to public opinion,
and even whether it is considered urgent may be a moral rather than a scientific
question. Therefore, resource allocation at national or regional levels may find itself
in the territory of ethics.
In considering the allocation of resources for nursing research, it is imperative to
identify the values of and beliefs about the nursing profession. Returning to my def-
inition: if nurses are not recognized as having any predominant and appropriate re-
sponsibility in the health care of a nation, then allocation of resources for nursing
research cannot be expected. Thus, professional responsibility and claim on re-
search resources should go hand in hand. This brings me to the macro/micro per-
spective, the profession's choices in relation to research involvement.
3 The Macro/Micro Perspective
How does the nursing profession view research? In the United Kingdom the poten-
tial power of the nursing profession is enormous, especially in relation to the ad-
ministration of nursing services and in its voice at government level. We also have
an increasingly powerful nursing voice in higher education. It seems reasonable to
assume that the increasing power of nurses has played an important part in the
growth of nursing research in our country. At the same time, it seems obvious that
only a relatively small part of the potential power of nurses is used to generate re-
search activity and there are significant differences among professional groups
within nursing. The differences are not merely due to different levels of scientific
understanding or to external constraints over which nurses may have little or no
control. Those factors may playa part, but it is only a part. Nursing research is
viewed differently by different professional groups and by individual nurses; it is
not equally valued, it does not appeal equally to the generic nursing opinion, and
there are not too many nurses who see nursing research as an urgent priority.
I do not intend to imply criticism; I am stating a fact. There are many nursing
administrators who give deep and serious thought to the services for which they are
responsible and who are highly motivated to facilitate the delivery of the best possi-
ble care, however this may be assessed. They consider it right, morally right, to allo-
cate their resources in terms of finance and manpower to the direct provision of
care, to nursing equipment, to amenities, and to comforts for patients rather than to
research, the outcome of which cannot be predicted. They make a deliberate choice,
which they can defend on moral and ethical grounds.
There are nurse teachers who consider it "better" to prepare their students to be
highly skilled in well-tried methods rather than allow them individual judgments on
124 L. Hockey
the basis of recent research. Research findings must be interpreted and used with
understanding. They pose an element of uncertainty which may generate anxiety.
There is not always a conflict, but there may be. To live with research is to live with
uncertainty. Nurses must not be uncertain; they must inspire confidence in their
patients which uncertainty may undermine. Tradition may be valued more highly
than innovation. If the discovery which might warrant innovation is clearly scientif-
ically credible, the issue is taken out of ethics, but there is often a measure of ambi-
guity within the concept of nursing science itself.
There are many clinically involved nurses who give devoted care to their pat-
ients but would rather dismiss any knowledge or awareness of nursing research.
They consider it unnecessary and irrelevant. I refer to the potential users of re-
search, not to active researchers. The time will come when they will have to be
aware of new knowledge through research reports for legal reasons, but then the is-
sue once again moves out of ethics. Ethics implies choices.
It seems, then, that on a macro/micro basis, looking at nursing research from
the perspective of the nursing profession there are ethical issues in relation to re-
search involvement, be it in the area of enabling, in the area of teaching, or in the
area of utilization.
4 The Micro Perspective
What is the individual's, the individual nurse's, position in relation to research in-
volvement? My focus here is on research activity, albeit for a limited period, for ex-
ample, to undertake one project.
Ought I to do it? Is it right for me to devote time and energy to research rather
than to the care of patients or to the education of students, depending on the nature
of may appointment? Have I a right to do it? Have I a right not to do it?
They are questions affecting conduct and they seem to conform to the criteria of
ethical questions. Can moral philosophy and ethics help to answer them? Many
ethical theories have been expounded over the years. They have attempted to give
us rules for our conduct when we have a choice. When and under what conditions is
our behavior, our conduct, praiseworthy or blameworthy? Are we blameworthy if
we do not use our nursing skills for the care of patients but, after having absorbed
resources vested in our professional preparation, deviate from the conventional
path into research? Are we praiseworthy for doing this because it may ultimately
improve conditions for patients or nurses? Is it motives or outcomes which deter-
mine the moral worth of research activity in nursing? Is it the utility of the activity?
It would be hard to defend it on the basis of the greatest good for the greatest num-
ber, but what about hedonism? Research activity brings its own credible pleasures
and rewards; is it defensible on those grounds? Is it a means to a pleasurable end,
that is, the extension of knowledge, or is it defensible as an end in itself because it
stimulates thinking and critical enquiry irrespective of the end?
Nursing research has characteristics which make it entirely different from any
other field of professional activity. In the first place, its potential usefulness is de-
pendent on other people. The end result is taken out of the hands of the actor. So,
while administrators can see the effects of their administration in terms of creating
The Ethics in Nursing Research 125
an environment which facilitates care, while the teachers can see the successes and
failures in their students and can take direct action in relation to them, while clinical
nurses relate directly to their patients and see the effects of their work, this is not so
for researchers. They produce findings but they usually have no control over the use
of these.
The other major difference between research and other types of nursing work is
that research is not prescribed anywhere within nursing and there is no mandatory
provision for it. There is no recognized grade of researcher within a health care sys-
tem, no salary grading, no career pattern.
The only exceptions to this lack of recognition and prescription are academic
departments of nursing. In universities, research is a recognized and valued part of
teaching responsibility. Where clinical settings are linked with university depart-
ments, the senior university teacher is also a senior professional with clinical re-
sponsibility. '!'here, the use of research becomes part of clinical practice; by use, I
mean its discussion, not necessarily its implementation. Such arrangements are
usual in medicine, but rare in nursing. They raise their own ethical problems in
terms of division of responsibilities and priorities.
In conclusion, the ethical issue of allocation of resources to nursing research,
which includes the provision of training opportunities, is relevant for a society
which places responsibility for certain aspects of health care on the nursing profes-
sion.
For that profession, striving to assert itself as being able and willing to accept
such responsibility, the ethical issues of research involvement must be urgent.
For the individual nurse any conflict between involvement in research and more
conventional areas of nursing work may remain a moral problem until the ethos of
nursing changes and the need to strengthen and, in many instances, begin to devel-
op a scientific foundation becomes a generally recognized, praiseworthy goal.
Many other ethical issues are worthy of debate. Given more space, I would have
addressed the issue of plagiarism, of informed consent, of confidentiality, and of the
communication of nursing research.
The ethical issues of nursing research are not a concern for researchers only; in
fact, it is the relationship between research and nursing which raises some of the is-
sues. Therefore, their thoughtful discussion by all who claim professional status is
urgent.
Reference
1. Curtin L, Flaherty MJ (1982) Nursing ethics, theories and pragmatics. Brady Bowie
Implication of Ethics and Nursing Research for Patient Advocacy
E. L. Bandman
In 1975, the Commission on Nursing Research of the American Nurses Association

completed and released the first document concerned with the ethics of nursing re-
search. This was just 1 year following the publication of the federal standards for
the protection of human subjects. As a result of the federal legislation, a national
system of review boards with responsibility for approving and supervising research
was developed in every hospital, college, university, or community agency conduct-
ing research to protect human subjects.
The American Nurses Association document was aptly titled Human Rights
Guidelines in Clinical and Other Research [1]. I say aptly because the conception of
human rights is at the core of the American Nurses Association Code for Nurses [2]
as well. In its very first provision; the code states the rights-based principle that
Each client has the moral right to determine what will be done with his/her person [2, p 4].
,
This is a clear statement of the right to self-determination. Other rights-based ethical
concepts in the code are that the client will be given all the information essential to
an informed judgment;
...to be told of possible effects of care; and (on the basis of this information) to accept, refuse or
terminate treatment [2, p 4].
This provision is acknowledgement of the client's right to respect and .of the Kan-
tian imperative:
Act so that you treat humanity, whether in your own person or that of another, always as an end
and never as a means only [3].
A further principle contained in the code related to this discussion is the concept of
advocacy. The third provision of the code says that
The nurse acts to safeguard the client and the public when health care and safety are affected by
incompetent, unethical, or illegal practice of any person .... The nurse's primary commitment is
to clients' care and safety. Hence, in the role of client advocate, the nurse must be alert to and
take appropriate action regarding any instances of incompetent, unethical, or illegal practice(s)
by any member of the health care team or the health care system itself, or any action on the part
of others that is prejudicial to the patient's best interests [2, p 8].
This rights-based ethical charge to the nurse who assumes the duties of a patient ad-
vocate contains the seeds of conflict between a rights-based ethical view of research
and research based on utilitarian social goals. This is but one example of the impli-
cations of different ethical orientations of research for the nurses' role as patient ad-
vocate. Some research is based on other than rights-based ethical orientations and
thus creates challenges and problems for the nurse-advocate who supports a rights-
based view exclusively.
Perhaps the Commission on Nursing Research realized the inherent conflicts in
a rights-based orientation since the guidelines speak to two sets of human rights -
those of the rights of qualified nurses to conduct research and to the human rights
Implication of Ethics and Nursing Research for Patient Advocacy 127
of the subjects of research [1, p 1]. The probability that at some point the rights of
the nurse investigator and the rights of the patient subject will come into direct con-
flict are contained in the first page of the document in the statement that
The subject needs to be assured that his rights will not be violated without his voluntary and in-
formed consent [1, p 1].
The next statement in this paradoxical document
...guarantees that no risk, discomfort, invasion of privacy, or threat of personal dignity beyond
that initially stated in describing the subject's role in the study will be imposed without further
permission being obtained [1, pp 1-2].
In other words, the nurse will obtain permission to violate the patient's rights, priva-
cy, or personal dignity. This is contrary to the Code for Nurses and the role of nurse-
advocate as that of "primary commitment. ..to the client's care and safety" [2, p 8].
These quoted statements are the research commission's attempt to resolve the
conflicts between the human rights of each individual to self-determination and the
rights of nurse researchers to put their design goals first and ahead of patient's
rights. Th'e guidelines state that each nursing practitioner has the obligation to sup-
port the principle of self-determination as the individual's moral and legal right, fol-
lowed by the statement that
The responsibilities attendant to safeguarding the rights of other people must be freely accepted
by nurses whether their roles by practitioners, educators, or researchers [1, p 2].
That statement of freedom contradicts the previous statement of the nurse's moral
obligation. If the nurse freely chooses, then there is no obligation for nurses to sup-
port the human rights of patients if it gets in the way of research goals. The commis-
sion impaled itself on the horns of a dilemma of either supporting the rights of the
investigator or the rights of human subjects in tough cases.
Thus, the concept of rights is not as simple as it may seem at first glance. The
concept of rights has been variously defined as "needs, interests, powers, claims,
and entitlements" [4, p 7]. The Codefor Nurses defines it as the moral right to decide
what will be done with the individual's person on the basis of freely given and fully
informed consent [2, p 4]. In the American Hospital Association's Patient's Bill of
Rights, it states that
The patient has the right to be advised if the hospital proposes to engage in or perform human
experimentation affecting his care or treatment. The patient has the right to refuse to participate
in such research projects [5].
My first example of research, which illustrates the conflict of rights inherent in
some research, is that of double-blind studies. Charles Fried makes the point that
randomized clinical trials, of which double-blind studies are one kind, both repre-
sent
...the best hope of advancing medicine and so alleviating suffering, but appears to do so only by
disregarding the rights of patients [6, p 143].
Moreover, Fried concludes that recognizing the patient's rights in this kind of
experimentation may be too costly in terms of the social benefits of the research [6].
This view states that the social goal of the greatest happiness for the greatest num-
ber, a goal-based ethical orientation of Bentham and Mill, takes priority over the in-
dividual's right to self-determination. Mill states that all persons .
128 E. L. Bandman
... have a right to equality of treatment, except when some recognized social expediency requires
the reverse [7, pp 77 -78].
This may well have been the ethical rationalization behind the Veterans Administra-
tion clinical trials of antihypertensive drugs. Patients with hypertension were ran-
domly assigned to receive either antihypertensive drugs or placebo in clinics in dif-
ferent cities. The study was double-blind because neither physician nor patient
knew whether the drug was a placebo or an antihypertensive. Only after
...the mortality and morbidity in the control group with severe hypertension was so much higher,
that the trial was discontinued and all the surviving patients in that group placed on anti-hyper-
tensive drugs [6, p 145].
The experimentation was continued for several years for less severe cases until the
same conclusion was reached. Fried states that even though the published reports of
the research go into great detail about procedures, nothing was reported concerning
what, if anything, was said to the subjects and the nature of the consent given [6].
This kind of randomized clinical trial has been reported extensively. Oral medi-
cation for the control of the blood sugar level in diabetics as a substitute for injec-
tions was tested in exactly the ,same way as the antihypertensive drugs. This re-
search, however, resulted in the unexpected finding that not only was the drug of no
benefit but that there was also iil significant number of cardiovascular accidents in
those on the oral medication. At that point, the code was broken and the research
ended [6, pp 145-146].
Similar research was done concerning coronary bypass surgery in hospitals
throughout the country. Some patients were referred to cardiologists who told them
that a study was involved in which they were free to participate and to receive the
best treatment for their cases. Only if subjects asked were they told that the choice
of either medicine or surgery, significant to their very lives, was decided randomly.
Obviously, in the cases cited, and in other doubleblind studies reported in which
nurses participate, the human rights of the subjects to self-determination based on
fully informed and freely given consent were absent. It appears that outright decep-
tion of the subjects was practiced through withholding of vital information such as
the fact that effective antihypertensive drugs were available to patients and that lack
of treatment was either harmful or deadly. Disrespect for human rights was shown
in not informing subjects that the choice of surgical or medical treatment for coro-
nary artery disease was not according to their best interests but according to a ran-
dom selection for research purposes. Again, deception was practiced violating the
duty-based orientation of Kant's dictum to always tell the truth [3]. The nurse re-
search participant in these cases who assumed the role of patient advocate based on
a human rights-based orientation would be obligated to tell the patients all of the
truth without omission of relevant information or the practice of deception and
fraud. In these two cases, the rights-based orientation supports the role of the pat-
ient advocate as a moral agent revealing truths. It might, however, result in the re-
fusal of some subjects to participate or the cancellation of the research. That raises
moral issues in regard to goal-based ethics and the loss of social benefit to be de-
rived from these findings. Double-blind studies of the kind described place the re-
searcher in an adversary relation to the subject because the patient may be harmed
or exploited on behalf of the research goals. It violates another of Kant's principles
to
Act only according to that maxim by which you can...will that it should become a universal law
[2, p 391.
It also violates another duty-based ethical principle which Kant states as
Act so that you treat humanity, whether in your own person or in that of another, always as an
end and never as a means only [3, p 47].
Kant's duty-based principles clearly support the rule that research be conducted for
the welfare of each subject and not for the ends of the researcher who uses human
beings as means.
The nurse advocate is fortified in her objection to anything less than fully in-
formed consent of the patient on the basis of both duty-based and rights-based eth-
ics. The same principle should be applied to faculty research involving students or
studies involving psychiatric patients, retarded patients, and other vulnerable
groups. In these low-status groups, the research is usually presented by the investi-
gator as one of great social benefit. For example, families of retarded children seek-
ing admission to the Willowbrook facility for the retarded in New York were told
that the research for which their consent was sought would be of great benefit to a
great many other children. The result, parents were told, might be a great social
good in the form of an antihepatitis vaccine, a goal-based ethical orientation. The
children whose parents signed the consent form were admitted to the facility with-
out waiting for months or years. They were given live hepatitis virus as the intended
basis for developing a vaccine against the hepatitis rampant in below-standard cus-
todial institutions. Here, human beings were clearly used for the goals of the re-
search design. This is true in many studies on psychiatric patients where proxy con-
sent is given by family or by the hospital administrator himself as guardian. The
situation is coercive as are studies by faculty using nursing students in their own
classes. The end is to test a particular strategy or to write an article or to complete a
dissertation. In one example, a nursing instructor was doing marketing research (for
which she was paid) for a vaginal tampon company using students in her own class.
Not only were her students placed in a position where their self-esteem and security,
in the form of grades or evaluations, depended on participation in the research but
students were also deprived of instruction time spent on the goals of the course.
Moreover, the research was trivial and really testing a marketing strategy. The prac-
tice of using fellow nursing students as subjects in student nursing research raises
the whole question of reliability and validity. Nursing students especially, seem
motivated to help other students by responding in as positive a manner as possible.
Sometimes, this can be controlled by deceiving the students regarding the hypothe-
ses to be tested, but should dishonest means be used to achieve honest ends and are
the ends honest if questionable means are used? Again, the human rights interests
of the subjects are set aside in favor of the research design and goals of the research-
er. In the case of students, the negative effects may be no more than wasted time. On
the other hand, it may reinforce students' doubts concerning the integrity of educa-
tion and health care as moral enterprises.
130 E. L. Bandman
The Nurse's Role as Advocate
Clearly, the nurse who participates in research and who considers herself to be a
patient advocate supporting individual self-determination may be in a dilemma re-
garding her role in some investigations. The nurse as patient advocate who opposes
double-blind studies and randomized clinical trials is not necessarily anti-intellectu-
al and anti-research. As the antihypertensive drug, antidiabetic drug, and coronary
bypass surgery studies show, patients were deceived and harmed by the trials. De-
ception is unnecessary. The nurse who sits on an institutional review board passing
on research or one who actively participates in studies can insist on the principle of
truth-telling. The investigator carefully explains to the patient how double-blind
studies work, the risks of experimental drugs, the probability or percentage of possi-
ble benefits, the significance of the 50% chance of getting a placebo, and the sub-
ject's right to discontinue participation at any time. Would this mean the end of
double-blind studies? Not if double-blind research is as carefully conceived as was
that of the Salk polio vaccine studies. The research was nationwide, randomized,
double-blind with a placebo, a)1d involved hundreds of thousands of American
children. The research protocol was fully revealed to parents before seeking con-
sent. Parents were informed of risks and promised first call on the vaccine, if suc-
cessful, and if the child was a control. The research worked out as both a great goal-
based, social benefit and to the benefit of each individual subject who wouldn't get
the vaccine any other way. Unlike, the research involving antihypertensive drugs
and coronary artery disease treatment, no deceit or harms of subjects occurred.
Both the human rights principle of self-determination and the duty-based principle
of treating each person " ... always as an end and never as a means only" [3, p 47]
were honored. The polio vaccine research shows that scientific knowledge need not
advance by fraud, deceit, force, insecurity, and financial rewards. The principle of
educating clients through complete disclosure of even randomized clinical trials re-
spects the right to self-determination, including unconditional support for client's
right to refuse. Any other position is morally impermissible from a human rights ori-
entation.
The nurse investigator as patient advocate practices candor and respect. If re-
search is conducted for the investigator's benefit, an existential choice, these facts
can be shared with the intended subject so that he or she can also freely choose to
participate or not. Candor of this nature is essential to the validity of much of nurs-
ing research conducted on students by classmates or teachers or outside investiga-
tors desiring access to classes of students. The element of coercion in research may
affect validity of the findings as well as the integrity of the instructional program. In
most research, academic and clinical, respect for individual rights can be fully sup-
ported while experimentation and investigation for social benefit goes on.
In some studies, however, such as the use of experimental drugs on senile or
psychotic patients which will not benefit them but may even be harmful, the nurse is
forced to make an existential choice. The alternatives constitute the dilemma inher-
ent in the American Nurses Association Human Rights Guidelines [1] between sup-
port of the human rights of the patient and the rights of the investigator to pursue
the goals of the research. The nurse with one foot in the scientific community may
choose to place both feet firmly on the path to scientific advancement through the
route of social benefit for the greatest number, subordinating the interests of the in-
dividual to the whole. Or the nurse may choose to be on the side of the patient as an
end and take appropriate action regarding what she believes to be research prejudi-
cial to the patient's best interests. That nurse is truly a patient's advocate with all the
trials, opportunities, and risks this position offers. In either case, the authentic
choice, the existential orientation, reflects consideration of the arguments and
reaches for a position which in many instances represents the paradigm of a ge-
nuine moral dilemma.
References
1. American Nurses Association (1975) Human rights guidelines in clinical and other research.
American Nurses Association, Kansas City
2. American Nurses Association (1976) Code for nurses with interpretive statements. ANA, Kansas
City
3. Kant I (1959) Foundation of the metaphysics of morals. (1785) Bobbs-Merrill, Indianapolis
4. Bandman EL, Bandman B (eds) (1978) Bioethics and human rights: a reader for health profes-
sions. Little, Brown, Boston '
5. American Hospital Association (1972) A patient's bill of rights. American Hospital Association,
Chicago
6. Fried C (1974) Medical experimentation: personal integrity and social policy. North-Holland,
Amsterdam
7. Mill JS (1861) Utilitarianism. Indianapolis: Bobbs-Merril, (1957)
Ethics and Research into Nursing Practice
R.Crow
1 Introduction
In discussion of the ethical issues which relate to nursing practice research, of cen-
tral concern is the research approach used to develop and/or test our nursing thera-
py, namely, experimental research using patients/clients as human subjects. I am
making the assumption that the major thrust in nursing practice research is to estab-
lish the scientific basis of practice through both advancing our understanding of
practice and exploring the worth or "value" of the therapy we advocate, i. e., re-
search to test the effectiveness of our nursing assessment! diagnosis and delivery of
care. Given this framework, I want first to identify the main ethical issues underly-
ing the use of human subjects in experimentation, then in discussion I shall attempt
to establish how far codes of behavior guiding nursing research cover the issues,
looking at the same time at the safeguards needed to ensure that nursing practice re-
search is carried out with due regard to a recognized ethical code.
Main Ethical Issues

The main guidelines where human subjects form the basis of experimentation are
laid down in the Declaration of Helsinki, which was drawn up by the World Medi-
cal Association in June 1964 [1]. The code of ethics concerns clinical research, where
a distinction is made between research combined with professional care - namely
therapeutic research - and nontherapeutic research the essential object of which is
purely scientific and without therapeutic value to the person subjected to the re-
search.
The basic principles covered (where the doctor is bound to the moral principle
that he/she must remain the protector of the life and health of the patient) are:
1. A requirement to conform to the moral and scientific principles that justify medi-
cal research
2. That clinical research should be conducted only by scientifically qualified per-
sons and under the supervision of a qualified medical man
3. That clinical research cannot legitimately be carried out unless the importance of
the objective is in proportion to the inherent risk to the subject and careful con-
sideration should be exercised where the personality of the subject is liable to be
altered by drugs or the experimental procedure
4. Meaningful consent of the subject must be obtained
On the basis of these principles, an ethical code for nursing practice research (where
nursing practice research is considered to be on a par with clinical research) should
cover four central issues:
1. There is a need to ensure that the moral and scientific principles of research are
maintained
Ethics and Research into Nursing Practice 133
2. There must be consideration of the balance between risk and benefit of the nurs-
ing therapy delivered to the patient/client
3. There must be meaningful consent
4. Careful consideration must be given to the safeguards required when carrying out
therapeutic and nontherapeutic clinical research
The important questio~ how far do the ethical codes for nursing research cover
these issues?
In answer to the question, it would seem that most of the codes currently avail-
able [2, 3, 4] address themselves to the issues of the moral and scientific principles of
research and meaningful consent, but when it comes to the problem of balancing
risk with the benefit and in consideration of a need to distinguish between therapeu-
tic and nontherapeutic research, they leave one with more questions than there are
guidelines given.
It is thus these latter two areas I wish to pursue.
2.1 Risk Balanced Against Benefit
In discussions of the ethics in nursing rese~rch, risk is interpreted in two ways [5]:
1. In relation to the "individual" subject or patient's recognition of it in the context
of informed consent (albeit with no mention of a distinction between therapeutic
and nontherapeutic research)
2. As it concerns the risk of harm to the subjects where harm covers the physical
risk, the potential degree of anxiety, fear, or distress which may be generated, and
the possible imposition of discomfort. It is this latter definition of risk which is
being referred to when balancing the benefits of therapy with its potential harm-
ful effects.
In order that we meet our responsibility to the patients, we must not only recognize
the sources of harm with some degree of certainty but also gauge the potential bene-
fits, that is, have some idea of potential therapeutic value of whatever is under test.
Yet there is not always general agreement in nursing circles about the "goals" of
care - in short we do not always agree on what effects we expect from the various
practices that we perform. Thus, how can we, with any degree of consensus, provide
an objective assessment of the potential therapeutic value?
Indeed, drawing on research sources there is not much consolation that help is
available for those who care to look. Most of the studies concerned with testing the
effects of care are not invariably analyzed solely in terms of statistical significance
between the different treatments. Scant attention is paid to the size of difference
produced and its clinical significance, e.g., is it worth reducing anxiety and, if so,
what size in reduction is needed before the results are effective? Also, what do we
mean by effective? There remains the implicit assumption that removal of painful
experiences and the increase of the positive/comforting components of health are
"a good thing." My deep concern is that these assumptions desperately need to be
put to the test, since we could be subjecting our patients to unnecessary research
and thus be unethical.
134 R.Crow
Still on the subject of risk, even if there was a clearer and more generally agreed
notion of therapeutic value, there remains the problem of the need to ensure that for
every nursing practice research proposal there is an objective assessment, that is, an
assessment by a nurse who has not been involved in the design and yet has the
scientific knowledge and the understanding of the ethical principles involved. This
demands that all Ethical Committees concerned with clinical research have at least
one nurse member. No such situation occurs in the United Kingdom [6] and from
reading the general literature I doubt that this is true elsewhere. What are we doing
about it, and have we the nurses so prepared?
2.2 Therapeutic Versus Nontherapeutic Research
I now want to tum to the question of whether, in nursing practice research, there is
need to recognize the importance of the distinction between therapeutic and non-
therapeutic research [7].
In the Royal College of Nursing of the United Kingdom's guidelines on Ethics
Related to Research in Nursing, NO mention is made of the distinction; rather there
is a statement which reads:
g) i(a) the nurse as researcher has no 'responsibility for the service, care/treatment or advice given
to patients/clients and should make this clear. Intervention should be confined to occasions
when a potentially harmful situation appears imminent.
It would seem from this that in the United Kingdom, if not further afield, nursing
has not recognized the potential ethical implication of introducing new "therapies"
into our everyday practice. Ought we not to insist that new therapies are tried under
strict scientific and ethical principles? For surely, the giving of any new untested
therapy is potentially hazardous, and should always be considered in relation to its
therapeutic value to the patient!client. Yet how often do we consider it necessary or
appropriate to ask the patient! client whether he agrees to try the new therapy,
assess the potential risk, systematically assess the effects such that we can evaluate
the benefits? There is no way of knowing what the balance of answers would be
throughout nursing worldwide, but there would seem to be a strong argument for
saying that recognition of the role of therapeutic nursing practice research and the
ethical principles entailed urgently needs to be addressed.
. It may also be timely for us to consider whether we need to distinguish between
clinical and non-clinical research. Clinical research is that pertaining to the pat-
ient's/ client's therapy, and the subjects are patients, selected for their representa-
tiveness. Nonclinical research is that pertaining to theoretical or basic sciences,
where the subjects are normal volunteers, recruited by letter, circular, notice board,
or personal contacts. The reason I raise this question is because I am becoming in-
creasingly uneasy about the rise in the number of nursing research programs where
patients are used as subjects and yet there is no justification of their clinical signifi-
cance for those patients' health status. The areas of particular concern are studies
on "communication." At the moment it would seem that there is an assumption that
because nurses are by definition involved in patient-nurse interaction, and hence
communication, that this makes a study of it "clinical." I would like to challenge
Ethics and Research into Nursing Practice 135
this view for the sake of airing the issue and suggest that studies looking at the com-
munication process per se are not clinical and therefore nurse researchers should
not select patients but recruit normal volunteer subjects. If we do not take ourselves
to task, we could in the future have the ethics of our practice research questioned.
The challenge is to establish what we consider nursing practice research to be and
sort out what is the central purpose of nursing when developing therapy.
References
1. World Medical Association (1974) Declaration of Helsinki. World Med J (1975 revision available
from World Medical Association, 1841 Broadway New York, N. Y. 10023) See: Br Med J (1964)
2: 177
2. Royal College of Nursing of the United Kingdom (1977) Ethics related to research in nursing.
RCN, London
3. American Nurses Association (1968) The nurse in research: ANA guidelines on ethical values.
Nurs Res 2: 17
4. Canadian Nurses' Association (1972) Ethics of nursing research. Can Nurse 9: 68
5. Hayler J (1979) Issues related to human subjects. In: Downs FS, FJemingJW (eds) Issues in nurs-
ing research. Appleton-Century-Crofts, New York
6. Norther Regional Health Authority (1978) Application for ethical approval: A report by the
working group in current medical/ethical pro'blems. Lancet 1: 87-89
7. Denham MJ, Foster A, Tyrell DAJ (1979) Work of a district ethical committee Br Med J 2:
1042-1045
Ethical Considerations for the Nurse Ethnographer
Doing Field Research in Clinical Settings
c. P. Germain
Ethnography literally means "portrait of a people." Ethnographic research provides

a descriptive analysis of a subculture and is the basis for theory development in
such subdisciplines as cultural, social, or educational anthropology. Traditionally
anthropologists have studied remote or exotic cultures but the need for ethnogra-
phic research of the many health care subcultures where nursing is practiced has
been cited by a number of nurse anthropologists.
Nursing and anthropology are similar in a number of ways. They share a view of
humans as holistic beings whose problems should be viewed in a systems perspec-
tive. Fieldwork and the research methods of participant observation and intensive
interviewing are essential ingredients of both disciplines. Cassell (1980), an anthro-
pologist, emphasizes that:
Unlike other modes of investigation,' fieldwork does not place human interaction outside the re-
search paradigm: instead, the paradigm is based upon human interaction, in all its richness, vari-
ety, and contradiction. [4, p31]
Glazer [7, P 25] suggests that ethical tensions are inherent in the effort to probe be-
hind the scenes of social life. The ethical considerations addressed in this paper
have been developed from a study of the research ethics literature and reflections
on my own ethnographic research of an adult cancer ward in a community general
hospital [6] and an ongoing ethnographic study of an abused women's shelter.
Clearance to gain entrance to initiate both studies took considerable time and was
obtained by submission of the same research proposal with necessary verbal expla-
nation to the appropriate administrative bodies, committees, and staff of the agen-
cies, as well as the committees of two universities charged with review of ethical
components of studies involving human beings.
Whether this latter type of institutional review is appropriate for ethnographic
research has been a matter of considerable debate because of its epistemological
divergence with experimental research. In the United States, institutional research
review committees were primarily formed for the protection of human subjects un-
dergoing biomedical experimentation or behavioral research in which ethical di-
lemmas and risk/benefit ratio could be largely determined prior to initiation of the
research. However, if the ethnographer enters a field situation as a true explorer, the
ethical issues and how the subculture identifies and deals with them cannot be
spelled out in advance. They become apparent as the researcher immerses herself in
the life of the subculture during the data collection phase.
Prior to my initial ethnographic research, I received training in field research
methods and idenpendently studied ethical guidelines such as the American Nurses
Association's (ANA) Human Rights Guidelinesfor Nurses in Clinical and Other Re-
search [1]. I also had a nursing awareness of potential ethical issues on a cancer unit,
such as the use oflife-prolonging technology or resuscitation ofterminally ill cancer
Ethical Considerations for the Nurse Ethnographer Doing Field Research 137
patients, neither of which occurred. However, many of the ethical dilemmas that did
occur were not anticipated. Dealing with these dilemmas led to an investigation of
the ethical guidelines of the discipline of anthropology and consideration of how
these can relate to nursing.
The American Anthropological Association published a statement of ethics in
1971 [5] (1976) which is much more explicit in dealing with field research than the
ANA research guidelines. Closely examined, however, conflicting positions are evi-
dent even within the statement on ethics. For example, one principle states:
In research, an anthropologist's paramount responsibility is to those he studies. When there is a
conflict of interest, these individuals must come first. The anthropologist must do everything
within his power to protect their physical, social and psychological welfare and to honor their
dignity and privacy. (p.183)
This principle does not give direction for the nurse ethnographer when members of
the subcultural group the institution purports to serve (e. g., the patients on a cancer
ward) are further victimized by more than their disease, that is, by those with greater
power, status, and authority in the subculture. By becoming researcher, the nurse
does not forfeit her advocacy role for the client of nursing services. This is the
source of potential ethical dilemmas.
Nurses have traditionally functioned'in institutions where they have limited au-
tonomy, power, and control of the work environment. When studying a nursing sub-
culture, however, power relationships, institutional constraints, and interactions
with members of other disciplines must be examined by the researcher, insofar as
they affect the life of the subculture. Reporting these phenomena may pose a risk
for some subjects and a benefit for others, though both risk and benefit are almost
impossible to measure.
Nurses using participant observation as research methodology in hospital situa-
tions may have greater conflict with recording and reporting about power relation-
ships and interdisciplinary issues because their socialization as nurses may have
been to the protection of the institution, the physician, and their nursing peers rath-
er than to the advocacy role for their clients. Perhaps this explains why there is so
little descriptive field research of nursing practice.
All researchers must deal with the rights of research subjects with regard to in-
formed consent, privacy, anonymity, confidentiality, and the risk-benefit ratio. Ad-
ditional ethical concerns of ethnographers include objectivity versus subjectivity
with regard to selection, recording, and reporting phenomena (bias); intervention
versus nonintervention in the activities of the subculture; and the scientific integrity
of the report. The two categories of ethical concern - rights of the research subject
and role functions of the nurse ethnographer - cannot be separated except for heu-
ristic reasons. In practice, they are inextricably intertwined and will be discussed in
that context.
138 C. P. Germain
2 Subject Consideration
2.1 Infonned consent
In ethnographic research informed consent of the study population deals mainly

with the privacy rights of individuals. While written consent is obtained for entry,
the procedure for informed consent differs for ethnographic research as compared
with experimental designs, which usually require a one-time, prior written consent.
Ethnographic research is conducted over a long period of time, sometimes a year or
longer. Various changes occur in the subculture and many persons enter and exit at
different points. Thus, the study must be explained to newcomers and consent con-
tinuously negotiated. Also, while the study might have a specific focus on a primary
subgroup of the total population involved in the study, such as professional nurses
or patients, secondary subgroups are also considered research subjects. They have
the right to be informed of the conduct of the study and to consent to participate.
Yet, as Benoliel states:
Signed consent forms are simply not a viable alternative in studying certain kinds of sociocultural
situations, and rigid procedures for informed consent based on the experimental model of re-
search do not make a good fit with the goals and methods of fieldwork. [3, p 125).
With regard to fieldwork, Cassell writes:

While conducting fieldwork, investigators have comparatively little power over those who are
studied: informants are usually free to leave the situation or to decline to enter interaction ... [4,
p30)
However, there is variation according to the type of institution being studied. In

health care institutions, patients are often captive and relatively powerless. They
may fear retaliation of some sort if they don't agree to participate as research sub-
jects. Staff on the lower levels of the hierarchy may feel obliged to participate as
part of their role requirements. Researchers need to be sensitive to these nuances
and be very clear about their informed consent procedures. Additionally, the costs
of individual subject and staff time required for interviews need to be part of the
risk-benefit analysis.
On the other hand, relatively powerless individuals may have a particular desire
to participate in ethnographic research. They may perceive an interview with the re-
searcher as an opportunity to express their opinions, to make a contribution, to be
listened to seriously, and to be co-equal with others in the setting in the role of cul-
tural informant.
Glazer points out that respondents have their own reasons for wanting to be in-
terviewed and suggests that:
The very attention and intimacy engendered by the interview encourages respondents to speak
more openly than they normally would. [7, p 26)
To avoid the misuse of sensitive material contributed by individuals the researcher

should repeatedly make clear that the interview is voluntary. The material should be
subject to recall if the respondent has second thoughts about his/her contribution.
This means that the researcher should be accessible for a period of time after an in-
terview has been recorded or that interviews, tape-recorded with permission, or
Ethical Considerations for the Nurse Ethnographer Doing Field Researcft 139
notes of interviews, can be reviewed by the contributor. Requests to withold certain

pieces of information from the published report should be honored as long as valid-
ity and reliability are not jeopardized. Certain material can be handled in the report
in such a way that the identity of individuals involved is protected. The ethical prin-
ciple of respect for persons, as stated in the Belmont report [2], warrants that people
should be treated as ends in telling their own story, not as means to the researcher's
ends.
During the data collection stage, the researcher has no foreknowledge of what
the final product of the research will be. Thus informed consent is never complete,
in the sense that individuals who volunteer information (which the researcher vali-
dates) may not fully understand the implication of more widespread dissemination
of the data provided if and when the report is published. Moreover, though much of
the descriptive data are provided by members of the subculture, they may not agree
with the analysis of the data and the conclusions derived. These are purely the re-
searcher's, guided by his/her own theoretical perspectives. As Wax indicates when
speaking of field-workers:
If they are competent as researchers, then they must function not merely as observers (gatherers),
but as interpreters and analysts. For knowledge is not simply to be plucked from the streets, and
byways, but must laboriously be assembled, integrated, and refined [15, p 25].
The level of knowledge and experience that a researcher brings to the field is differ-
ent from that of members of the subculture being studied, including members of the
nursing subculture. Regan [12] states that ethicists must constantly cope with the
fact that people are often totally unaware that there are ethical problems: "A lawyer
or a nurse or a doctor may lack sensitivity to the base value at stake in a given issue"
[12, 17]. Thus one must seriously consider what is the ethical way to communicate
the research report and recommendations to members of the subculture studied
when no provision can be made for the resources necessary to effect the changes in
the system for a higher level of care.
2.2 Privacy, Anonymity, and Confidentiality
The usual precautions for the protection of subjects in the publication phase of eth-
nographic research are the use of pseudonyms for persons, locations, and institu-
tions; the alteration of minor details and events to aid disguise; and a time lag in
publication. Using such methods, the researcher aims to protect the identity of the
participants from the broad public, but it is likely that members of the study popula-
tion are able to identify themselves and each other in the report. The extent to which
the descriptive raw data, or the analyst's interpretations, can be used in a harmful
evaluative way by authority figures in the subculture is a concern.
The essence of ethnography is that members of the subculture give their own
views of their own situations. Individual views, including motives and meanings of
actions, given privately to the researcher, may vary widely. Also, during the data col-
lection phase many doors are opened to a nurse researcher that are ordinarily not
open to a member of the nursing staff. Individuals not only respond to questions
but often seek out the researcher and provide what they consider to be significant
140 C. P. Germain
material that social scientists might label "backstage" data. Processing this may
pose a difficulty, since nurses traditionally have been socialized to keep certain
backstage material from public dissemination. However, when such data are a sig-
nificant part of the subculture being studied, they must be ethically treated as any
other significant pieces of data. The principle is to use that material that provides
rich, cultural description of continuing significance, as opposed to idiosyncratic oc-
currences. The researcher might not like to deal with potentially controversial mate-
rial, but it becomes unethical not to deal with it.
Hansen states that confidentiality must be considered along with the rule gov-
erning any scientific enterprise:
...that is, that the scientist's analyses and conclusions must be adequately documented by refer-
ence to the concrete data on which they are based. Only in this way can conclusions presented be
adequately assessed by other scholars and validated (or disconfirmed) by further research [8,
p132].
Tilden's comment is right on target. She states:

If the investigator has been completely candid about his study, has constantly negotiated consent
with his actors, and has involved them in every step of the way as participants and coinvestiga-
tors, then publication should bring few surprises to the group [13, p 78].
2.3 Risk-Benefit Ratio
Risk-benefit ratio considerations weigh the potential harm to individuals, the sub-
culture, or the institution that might result due to loss of privacy, anonymity, and
confidentiality against society's right to scientific knowledge.
Risks occur during the data collection phase and at the time of publication of
the ethnography. Risks are minimized, however, when participation of individuals
is voluntary, contributions of individuals and subgroups are carefully validated, the
researcher's role is publicly known rather than concealed in any way, and efforts are
painstakingly made to preserve anonymity of the subculture and its members at the
time of publication ofthe report.
The scientific benefit is that ethnography provides descriptive theory and analy-
sis of a subculture as well as hypotheses for more rigorous research designs. An eth-
nography also becomes part of the history of a subculture. Secondary benefits of the
research are difficult to assess for the group being studied. However, presentation {)f
the "reality" of a health care subculture can lead to improvement of the quality of
care in similar subcultures by providing a data base for the examination of health
care system needs and problems. Some benefits are believed to accrue to individu-
als in the subculture who have an opportunity to "tell their own story."
Additional risk-benefit considerations for subjects are integrated in other perti-
nent parts of this paper. It should be noted that the researcher is subject to various
risks such as injury, infection, and legal involvement (field notes of anthropologists
have been subpoenaed).
3 Researcher Considerations
3.1 Objectivity Versus Subjectivity
Researcher bias can arise due to prior nursing socialization as well as personal and
professional experiences in similar subcultures. There is also the possibility of bias
when studying the members of one's own profession. Thus, a determined effort
must be made to attend to the various elements that contribute to an unbiased, ho-
listic view of the subculture. Quint [11] emphasized the necessity of recognizing
one's inner conflicts and biases and using them as an essential part of the data being
collected and analyzed.
3.2 Intervention Versus Nonintervention
As a research scientist the ethnographer is trained to stand back and observe and
not to intervene, though some reciprocity in the activities of the subculture is appro-
priate. On the other hand, not only is the nurse socialized to intervene in health care
situations, she also carries a social resp6nsibility to do so by virtue of her license to
practice.
My identity in the research subcultutes is primarily as a researcher who is also a
nurse with an interest in the problems of the people being studied. Participation in
the care of patients or clients is limited to meeting immediate needs for support,
safety, comfort, or physical care when these needs are obvious or requested and a
staff person is not immediately available. Reciprocity with the staff takes the form
of consultation regarding client care problems, the provision of relevant articles
from the literature, transportation of clients and similar minor tasks, and contribut-
ing unconfidential information regarding clients to the staff which is perceived to be
necessary for their care but unlikely to be communicated to the staff, e. g., specific
concerns regarding postdischarge care. Obviously a good deal of time is spent lis-
tening to patients, families, and staff. Since this provides a source of emotional re-
lease and ventilation for them not otherwise available, I do intervene. But, as Valen-
tine states:
Nor do we feel it is always possible to avoid intervention, especially in participant ethnography
which requires that one constantly interact with the community not just as observer but also as
fellow citizen [14, p 105]
Overall, my role is the low-keyed observer-as-participant, which allows movement
in and out of pertinent situations smoothly. According to Junker:
This is the role in which the observer's activities as such are made publicly known at the outset,
are more or less publicly sponsored by people in the situation studied, and are intentionally not
"kept under wraps." [9, p 37]
This aspect of the participant-observer continuum permits comparative detach-
ment, objectivity, and empathy as explained by Junker [9, p 36], although in the
course of the research all roles on the continuum are probably assumed at some
point. However, many researchers would agree that the full participant role cannot
ethically be assumed in a deliberately covert, deceptive way.
142 c. P. Germain
It is conceivable that nurse researchers will find themselves in fieldwork situa-
tions in which it would be ethically intolerable to stand by and observe cultural
scenes, such as situations of exploitation or threat of real harm to members of the
study population. Not to intervene would connote passive acceptance. In such situ-
ations, as Pelligrino states, "whether to act or not to act in order to protect the pat-
ient is the final test of one's moral integrity" [10, p 29]. The nurse researcher must
weigh possible or even probable termination of the research, and thus the loss of so-
cietal as well as personal, professional gain, against the immediate risk of harm to
individuals in the setting.
4 Conclusion
Ethical dilemmas for the nurse ethnographer doing fieldwork in clinical settings oc-
cur both during the data collection phase in the field and at the time of writing and
disseminating the report. In the clinical setting, the ethical dilemmas faced by the
nurse ethnographer are those that are faced with varying levels of awareness by
nurSes and other respondents in those settings. The nurse researcher must decide
when to stand back and observe or listen to how the subculture identifies and deals
with actual issues and if, when, aQ-d to what extent to intervene. This may prove
quite discomforting because of the different levels of knowledge and ethical aware-
ness, experiential background, and value system of the researcher compared with
those of the respondents. Working through ethical dilemmas is a necessary part of
the fieldwork experience and a growth experience for the investigator. Publication
of the way ethical dilemmas are dealt with becomes a resource for readers of the re-
port who can vicariously share the experience of others in learning to deal effective-
ly with similar occurrences in their own clinical settings.
References
1. American Nurses Association (1975) Human rights guidelines for nurses in clinical and other
research. American Nurses Association, Kansas City
2. The Belmont Report (1978) Ethical principles and guidelines for the protection of human sub-
jects of research. (The National Commission for the Protection of Human Subjects of Research.
DHEW Publication No. (OS) 78-0012) U. S. Government printing office Washington, D. C.
3. Benoliel J (1980) Research with dying patients. In: Davis A, Krueger 1 (eds) Patients, nurses,
ethics. American Journal of Nursing Company, New York
4. Cassell J (1980) Ethical principles for conducting fieldwork. Am Anthropol 82: 28-41
5. Council of the American Anthropological Association (1976) Statements of ethics. Principles of
professional responsibility. In: Rynkiewich M, Spradley J (eds) Ethics and anthropology: di-
lemmas in fieldwork. Wiley, New York
6. Germain C (1979) The cancer unit: an ethnography. Nursing resources, Wakefield
7. Glazer M (1980) The threat of the stranger: vulnerability, reciprocity, and fieldwork. Hastings
Center Rep 10: 25-31
8. Hansen J (1976) The anthropologist in the field: scientist, friend, and voyeur. In: Rynkiewich M,
Spradley J (eds) Ethics and anthropology: dilemmas in fieldwork. John, New York
9. 1unker B (1960) Fieldwork: an introduction to the social sciences. University of Chicago Press,
Chicago
10. Pelligrino E (1980) The ethics of nursing research some special aspects. In: Lenz R, Proulx J,
Kreider M, Damrosch S (eds) Ethical dimensions of nursing research. Proceedings. University
of Maryland, School of Nursing, Baltimore
11. QuintJ (1967) Role models and the professional nurse identity. J Nurs Educ 6: 11-16
12. Regan G (1980) Response to Dr. Aroskar. In: Lenz R, Proulx J, Kreider M, Damrosch S (eds)
Ethical dimensions of nursing research Proceedings. University of Maryland, School of Nurs-
ing, Baltimore .
13. Tilden V (1980) Qualitative research: a new frontier for nursing. In: Davis A, Krueger J (eds)
Patients, ethics, nurses. Am J Nurs Co, New York
14. Valentine C (1972) Models and muddles concerning culture and inequality: a reply to critics.
Correspondence. Harvard Educ Rev 42: 97-108
15. Wax M (1981) Correspondence. Field-workers and their hosts. Hastings Center Rep 11: 25
Additional Reading
The Final Regulations Amending Basic DHHS Policy for the Protection of Human Research Sub-
jects (1981) Federal Register 46: 8366-8392
Attitude of Nurses to Euthanasia of Terminally III Patients
v. B. Shachar
Nurses' attitudes to euthanasia have been examined in one general hospital in the
center of Israel. Before discussing the fmdings of this research, I would like to dis-
cuss some ethical, legal, and nursing aspects of euthanasia.
The term euthanasia has a Greek origin: eu, pleasant, easy, painless; thanatos,
death. The term refers to painless death; from a practical viewpoint, euthanasia re-
fers to activities aiding in easy and painless death [5]. In modern society determining
death and the time of death is becoming more and more controversial. Advances in
medicine and technology have made possible the prolongation of the life processes
in persons who would in the past have been considered dead [7]. The passing point
between life and death is becoming more and more difficult to determine. Is a hu-
man being, suffering from severe head injury who is being kept alive in a vegetative
state by artificial respiration and intravenous feeding with the heart still beating,
alive or dead? What is the quality of life? Any activity or treatment that would pro-
long life under such conditions raises the question of euthanasia.
2 Types of Euthanasia
Legally we can define types of euthanasia:

1. Active euthanasia,
2. Passive euthanasia,
3. The supplying of narcotics,
4. Aiding in suicide
2.1 Active Euthanasia
An action or activity that brings about the death of a human being is active euthana-
sia. The law in Israel and other countries (especially the Anglo-Saxon countries)
considers active euthanasia as murder and the punishment is possible life imprison-
ment.
Article300 of the Israeli Criminal Law (1977) states: "He who causes with
premeditation the death of another human being shall be accused of murder and
sentenced to life imprisonment." I must stress that the law has no regard for motive.
2.2 Passive Euthanasia
The doctor is under no obligation to undertake unusual activities, "activities that a

reasonable doctor would not perform." The doctor-patient relationship is contrac-
tual. The moment the doctor undertakes the responsibility of treatment he should
Attitude of Nurses to Euthanasia of Terminally III Patients 145
act "skillfully and according to medical ethics." From this there follows that if the
patient is conscious and refuses treatment, especially unusual treatment, there is no
obligation on the part of the doctor to give such treatment and he is exempted from
criminal responsibility [3]. Furthermore, medical ethics do not require a doctor to
perform unusual or "heroic" activities.
2.3 The Use ofNarcotic Drugs
The question arises, what is behind the use of a narcotic drug? Is it used only to re-
lieve severe pain or is it given continuously, with the intention of shortening the pe-
riod of suffering? This question has not been tested legally because of the difficulty
of finding evidence [8].
2.4 Aiding in Suicide
Article 302 of the Israeli Criminal Act (1977) states: "Anyone who persuades, ad-
vises or aids in suicide is sentenced to 20 years of imprisonment." In Israel aiding a
person who wishes to die is prohibited. IIi the United States a statute of the State of
California (1976) allows a person to write'a "living will" in which he can request the
termination of any treatment that would prolong his life. A person can sign such a
will 2 weeks after a diagnosis has been made and it is carried out 1 month from the
day of signing. In 1977 seven more states in the U. S. passed similar statutes (Neva-
da, Oregon, North Carolina, New Mexico, Texas, Arkansas, and Idaho) [2].
3 The Ethical Problem
This is the problem of the value and sanctity of life. Who is to decide when life has
become of no value and that death is to be preferred: the patient, the family, the
doctor? Who is to decide and who is to perform euthanasia and under what condi-
tions [4]? I shall not enter a discussion on these questions. I would only say that the
medical ethical code does not require a doctor to give heroic treatment. The Hip-
pocratic Oath states: "I will not give a fatal draught (drug) to anyone if I am asked,
nor will I suggest any such thing."
Both the Christian and the Jewish religions are against euthanasia. It is forbid-
den to perform any activity that would bring on death in a dying person at any
stage, and he who does is considered a murderer. Nevertheless, progressive streams
in Judaism believe that a human being facing the termination of life should not be
intercepted by artificial measures (Rabbi Eliezer Waldenberg) [6].
146 V.B.Shachar
4 The Research
The aim of this study [1] was to examine the attitudes of nurses toward euthanasia
and the factors that affect them.
1. To examine attitudes toward the terminally ill patient and his family
2. To examine nurses' attitudes toward life and the prolongation of life
3. To learn about nurses' attitudes toward death, euthanasia, and the termination of
life and the factors that affect them
4. To know how nurses solve conflicts and moral dilemmas connected with eutha-
nasia
5. To understand how nurses cope emotionally with the terminally ill patient and
his family
4.1 Variables that Were Examined
1. The kind of department and the number of terminally ill patients in it. It was as-
sumed that the type of department affects the nurse's attitude.
2. The degree of closeness and intimacy with patients, assuming that the nurse's atti-
tude changes as she is in clo~e relationship with the patient or with the doctor
(e. g., staff nurse or head nurse)
3. Professional level. It is assumed that the more professional the nurse, the more
different her attitudes towards life and death. Professional level is connected with
the previous variable also. Generally, the more professional nurses have adminis-
trative roles in the hospital.
4. Personal involvement and experiencing death situations in the nurse's family. It is
assumed that a nurse who had herself experienced death situations and crises
could have attitudes different from those of a nurse who had no such experience.
4.2 The Testing of Variables
The variables were tested by presenting cases and events to nurses in five depart-
ments. The nurses were requested to express their attitudes to the given events. The
events represented ethical and moral dilemmas to life, death, and euthanasia.
Several evants were represented:
1. The doctor has a positive attitude and the nurse is against.
2. The doctor is against euthanasias while the nurse has a positive attitude toward it.
3. An event representing the relation to the terminally-ill patient's family and the de-
gree of considering their opinion.
4. An event representing a grave conflict between doctor's and nurse's attitude and
the ways the nurse resolves these conflicts.
The sample population consisted or 44 nurses from one general hospital who were
interviewed in five departments that were chosen according to the hypotheses. The
departments were: pediatrics, medicine, surgery, intensive care, and oncology. De-
partments with small numbers off terminally-ill patients were compared with de-
partments in which most of the patients are terminally ill or are suffering from life-
threatening conditions. In each department all the nurses on different duty shifts
were interviewed. The sample included 21 registered nurses. 15 practical nurses and
8 student nurses [1]. Of the 36 graduate nurses interviewed, 11 were headnurses or
assistants and 25 were staff nurses.
Some demographical findings were shown in Table 1.
Table 1. Demographic fmdings

Marital status Age of nurses
68% Married 50% Below 20
32% Single 35% 20 to 30
15% 50 to 60
Birthplace Professionellevel
% N % N Level
43.2 19 Israel 47.7 21 R.N.
38.6 17 at least 10 years in Israel 34.1 15 P.N.
-;-1;;.;8;.:::.2=---_ _ 8 (Russian) 2-5 years in Israel 18.2 8 Students
100 100 44
Role in the department
% N
25.0 19 Head or assistant
56.8 25 Staff nurse
18.2 8 Students
100 44
4.3 Results
4.3.1 Attitude toward Euthanasia
It is interesting to note that 43% of the nurses (19) had positive attitudes toward ac-
tive euthanasia (Table 2).
Nurses attitudes to massive use of narcotics even if it will hasten death: 45% (24)
had positve attitudes towards giving a lethal dose of a narcotic: out of these 38.6%
would inject it themselves and 18.9% would ask the doctor to do it.
Table 2. Positive or negative attitude toward Euthanasia

% N
20.5 13 Positive attitude for maintenance of life only

27.3 12 Positive attitude to passive euthanasia
43.3 19 Positive attitude to active Euthanasia
148 V.B.Shachar
Table 3. Nurses attitudes to massive use of narcotics even if it will hasten death
% N
44.5 24 Positive attitude toward giving a lethal dose
38.6 Would inject it themselves
18.9 would ask the doctor
27.3 12 Positive attitude toward giving narcotics to ease pain
71::;.;8~.2=--_ _ _---;78_ _ _ _ _ Negative attitude toward giving narcotic at all
100 44
The nurses were asked what their attitude is towards Active- Voluntary Euthanasia
and if a patient would sign a "living will" and the time would come to carry it out,
what would they do? 41 % (18) answered they would respect the will and would car-
ry it out.
(Nurses were asked what their attitude toward Active Voluntary Euthanasia is and if a
patient would sign a "living will" and the time came to carry it out, what would they
do?)
Table 4. Nurses attitude to Voluntary Euthanasia (active)
% N
40.9 18 Respecting the contract and would carry it out

18.1 8 Indentifying with the contract but would refuse to carry it out
20.5 9 Would not identify with the contract but would fulfill doctor's
order
-;.;2::;.;0"'.5'---_ _ _---;9:;-_ _ _ _ _ Would not identify and would not carry it out
100 44
How does the nurse solve conflicts and ethical dilemmas? A case was presented in
which the nurse's attitude is in favor of prolonging life, while the doctor has decided
that there is nothing to be done and to give the patient suffering from metastatic
cancer a narcotic drug intravenously.
Nurses' responses to such a dilemma were: 61 % (27) would not fulfill doctor's
order when it is against their conscience; of this number 36.3% (16) would refuse
absolutely while 25% (11) would manipulate the orders like asking another doctor
in order to get a different directive.
TableS. Nurses' responses to dilemmas (conflicting situations)
% N
61.6 27 Nurses would not fullfil doctor's order
36.3 16 Would refuse absolutely
25.2 11 Would manipulate the situation (asking another doctor)
20.3 9 Would fulfill the orders because "we cannot disobey"
..,.1=-=8:..:;.2=--_ _ _---,.::.8_ _ _ _ _ Would try to change the orders.
100 44
It is interesting to note the difference in behaviour found between nurses born in Is-
rael and those who were new immigrants. Those from Russia conceived the doctor's
instructions as "something sacred" while the Israeli nurses, especially those regis-
tered, perceived their role as professional with independence.
Table 6. Nurses attitudes towards involving the family of the terminally-ill patient with the doc-
tor's decisions. 47% (21) thought that there was no need to involve the family, only the doctor
should decide
% N
47.7 21 Not involve family (doctors decision only)

22.8 10 Doctor's decision and family
-;-2;:9:,.::.5::..-_ _ _~1::_3_ _ _ _ _Involve those families that are for life maintenance
100 44
Table 7. Nurses attitude toward personal initiative aiding in Euthanasia. This was studied by pre-
senting a case in which the nurse caused some damage to a breathing machine. 65% (29) had a neg-
ative attitudes to the personal initiative of a nurs.e. Nurses attitudes towards involving the family of
the terminally-ill patient with the doctor's decisions. (By representing a case of a baby connected to
a breathmachine)
% N
65.9 29 Negative attitude to personal initiative

20.5 9 Identify with the attitude but not agree
~13,:,-.6=---_ _ _----;6.:;-_ _ _ _ _ Understanding the approach but not agree.
100 44
Findings: With Significant Correlations
Examining the relations between variables proved some of the initial assumptions:
1. A correlation was found between the kind of department and the attitudes of Eu-
thanasia. In a department with a large number of terminally-ill patients, the
nurses' attitudes to Euthanasia, even active Euthanasia, are positive.
2. In all departments except Pediatrics, nurses refuse to carry out instructions which
go contrary to their conscience and beliefs. In the Pediatric Department we stud-
ied, the staff was comprised mainly of practical nurses and nurses-maids; this
could explain the differences in the tendency to carry out doctor's instructions in
such situations.
3. Correlation between department and family involvement.
In the Department of Oncology and Intensive Care there is a tendency to involve
the family because of long hospitalization and intimate relationships with families.
In the Pediatric Department they were all against involving the family. One of the
reasons for this could be that it is hard for the family to decide on Euthanasia for
their child.
150 V. B. Shachar
Conclusions
1. A correlation was found between the kind of department, the place in which the
nurse works, the team with whom she is working and her attitudes. The nurse
identifies with the values of the team she is working with.
2. Nurses tend today to act in a professional way with accountability, i. e. to receive
instructions, to judge them and to take responsibility and not just to carry out the
instructions.
3. A lack of knowledge in legal, moral and ethical aspects of nursing.
4. Hospital stafftends not to involve the patient and his family in decisions connect-
ed with treatment.
5. There is a need in nurses for self-expression - for sharing of emotions and feel-
ings and for advice while treating the terminally-ill patient and his family.
6. The study was carried out with a small sample and in one hospital, and it might
be interesting to do a study on a larger scale.
7. There is a need for more involvement of patients in their treatment and to receive
their informed consent.
In summary. It is known that Euthanasia is actually taking place in hospitals but no-
body talks about it. It is done involuntarily without consulting the patient or his
family. There is a need for legislation on Voluntary Euthanasia and "Living Will"
and to assign a committee in every hospital that would decide on the continuity of
treatment or its cessation.
References
1. Ben-Shachar V (1980) Attitudes of nurses to euthanasia of terminally ill patients. Master's Degree
Dissertation, Tel-Aviv University
2. De-Vries A, Carmi A (1979) The dying human. Turtledove. Tel-Aviv
3. Etzion R (1973) Euthanasia. Master's Degree Dissertation. Tel-Aviv University
4. Mappes T, Zambaty J (1978) Biomedical ethics. McGraw Hill, New York
5. Rachel J (1978) Active and passive euthanasia. In Mappes J, Zambaty J (eds) Biomedical Ethics.
McGraw Hill, New York
6. Vishlitzky L (1977) A medical guide of traditional judaism. The Institute of Medicine and Juda-
ism, Jerusalem
7. Voluntary Euthanasia Society (1970) A plea for legislation to permit voluntary Euthanasia. Vo-
luntary Euthanasia Society, London
8. Williams G (1966) The sanctity oflife and the criminal law. Knopf, New York
Decision Making
A Framework for Resolving Ethical Dilemmas

in Nursing Education
J. Rosenkoetter and M. Rosenkoetter
In the last few decades, the complexities ofliving have multiplied geometrically and
so have the ethical dilemmas that confront us all. Understandably, then, there has
been a burgeoning interest in ethics and moral philosophy. In nursing, there has
been a parallel increase of attention directed toward ethical issues in nursing prac-
tice and toward the teaching of ethics in nursing programs. As Davis and Aroskar
state, "The nurse is concerned with values, choices, and priorities related to the
'good' of the individual, the profession~ and society "[8, p 19]. It seems consistent
then that the scope of this concern must be broad enough to include nursing educa-
tion. However, little appears in the literature relating to an ethical base for this area
of endeavor.
While faculty and students alike need to address themselves to ethical issues in-
volving patient care, they must also address those issues inherent in the education
process, whether they arise in the clinical setting, the nonclinical instructional set-
ting, or within the larger educational milieu. They furthermore must address those
issues in a reflective, informed, and rational manner. Thus, the need arises for an
ethical framework, germaine to the educational setting, which facilitates the resolu-
tion of ethical dilemmas.
Fromer [11] describes an ethical base as
... a system of moral principles, rules of conduct about a particular class of human actions or a
particular group of people. Ethics is also that branch of philosophy dealing with values relating
to human conduct in respect to whether certain actions are right or wrong and whether the mo-
tive and ends of such actions are good or bad.
By virtue of involving goodness, or the rightness or wrongness of a situation, ethics

includes a study of values - those concepts, beliefs, and attitudes which are sanc-
tioned by a person or group of persons within the context of society. Evolving over
time, ethics become standards for behavior [10, p 9] which reflect one's beliefs.
These standards convey the moral essence of a person and collectively are demon-
strative of the ethical codes of a profession.
Ethical beliefs precipitate feelings but must be processed by the mind. Simply to
feel that an act is right or wrong without fully comprehending its significance or its
consequences is to deny oneself the freedom of formal reasoning, a process re-
served by evolution for human beings alone. In utilizing moral principles as integral
parts of an ethical belief structure, humanity is indeed separated from infrahuman
beings. Charles Sumner stated that "the true grandeur of humanity is in moral ele-
vation, sustained, enlightened and decorated by the intellect of man" [9, p 407].
152 J. Rosenkoetter and M. Rosenkoetter
Sigman has indicated that "Responsible ethical choice .. .involves responsibility,

accountability, risk, commitment and justice" [15, p 40]. When making ethical deci-
sions, a person needs to be not only responsible and accountable but also aware of
the risks involved and committed to both the process and the outcomes. Justice, in
the sense of fairness, is an underlying concept. Sigman continues that an ethical ac-
tion must be " .. .intelligent, reflective ... , free ..., responsible, and consistent with
values ..." [15, p 41]. Justice, however, does not presuppose freedom. A person can
provide for unmitigated fairness and concern for the interest of others without per-
mitting them freedom [13, p 103] or freedom of choice. Commitment is also neces-
sary, but it must be genuine, not merely blind devotion to a system formalized by
others [2, p 299].
Callahan and Bok [5] propose that an ethic becomes
...a type of corrective vision. [It] ...relies heavily on the distinction between the descriptive and
the prescriptive, between what is and what ought to be. It throws the accepted world into a new
light, an unexpected horizon; it opens up new possibilities for action, so that behavior that a mo-
ment ago seemed so plausible and imperative now loosens its hold and its power to compel
(P240).
Through ethical reflection, other alternatives, other choices, once discarded now
seem more relevant.
Nursing education, by its very essence, is concerned with the development of
undeveloped potentials. In being such, it is characteristically teleological - directed
by an image of its product, namely, the learned student [3, p 33]. Some time ago,
John Dewey [1, p 120] suggested that it is essential for the student in this quest, to be
able to relate the intellectual and the moral. The student needs to understand the
moral and ethical aspects of intellectual choices and conflicting or potentially con-
flicting realities. Moreover, it is paramount that the student have situations to which
values are relevant and concepts can be applied. According to Dewey, "The attempt
to attach genuine moral considerations to the mere process of learning and habits
which go along with learning, can result only in moral training which is infected
with formality, arbitrariness, and an undue emphasis upon failure to conform"
(p 121). It is the responsibility of faculty to provide situations that promote the ethi-
cal enhancement of students.
Since Curtain [7, p 5] and others have stressed that nursing is indeed a moral art,
an understanding of the ethicomoral aspects of nursing practice and nursing educa-
tion becomes essential. To gain this, both faculty and students need to have the op-
portunity to develop and utilize skills in ethical decision making. If the two are to
realize ethical growth, decision making must be a consciously rational and reflective
process. For as Sartre has said, "Man is nothing else but what he makes of himself'
[6, p 83].
Faculty can no longer simply be teachers, guarding their skills and possessions
of the past [2, p 287], protecting their knowledge and imparting it sparingly and ap-
propriately. Nor can they be what Barnes called " ... pragmatic realists. Secretly con-
tent with things the way they are ... ".
In Buber's view, the effective instructor develops self-awareness in order to edu-
cate effectively. As a result, the educator learns that there is a major point of access
to the student, namely, the student's confidence [4, p 106]. Without confidence pred-
A Framework for Resolving Ethical Dilemmas in Nursing Education 153
icated on trust, an instructor has little hope of assisting the student learn to choose
between right and wrong, between what ought to be and what should not be. Belief
in the student is utmost in this process; reciprocally, the student must be able to be-
lieve in the instructor. The words of Kahlil Gibran [16], "I believe in you and I be-
lieve in your destiny," (p 38) seem an effective beginning for student-faculty interac-
tions.
Morris states that "If education is to be truly human, [however,] it must some-
how awaken awareness in the learner - existential awareness of oneself as a single
subjectivity present in the world" [12, p 110]. This awareness as a nurse begins with
the faculty. Faculty must be aware of themselves as human beings, their values, the
choices they are making, and the consequences of those choices. In being bothre-
sponsible and accountable, they must be aware of existing standards and codes of
acceptable behavior. They need to constantly be aware of the rights of not only the
patient but also of the student and even of other faculty members. Their decisions
must be clearly focused within the framework of societal expectations and fully ac-
knowledge the limitations of any situation. Self-awareness further helps both the
student and the faculty to control bias [14, p 706], by helping each to view the basis
of choices in perspective.
To achieve all of this, it is essential that faculty take part in the lives of their stu-
dents [4, p 106], helping them to deal with their thoughts, their values, their choices,
and the consequences of those choices. Students need to be able to respect and trust
faculty, and the faculty need to be able to respect and trust students before attempt-
ing to deal with their choices. This implies knowing and reciprocity. Faculty need
not try to impose their values and ideas on students, but they can state them. It is im-
portant for students to know how the faculty feel, what they have chosen, and what
they believe. But imposing one's beliefs on another is to deny that person freedom
of choice and the right to be right or wrong.
Students have the right to be wrong, but not at the expense of the patient. Facul-
ty therefore assume a variety of roles, including that of facilitator and decision mak-
er, not in an attempt to impose their beliefs on the student, but in order to intercede
according to the best interests of the patients. Students can learn from this process.
They learn about ethical decisions and about conflict as an elemental ingredient of
the decision-making process. They can learn that often there are a variety of alterna-
tives and that there may be more than one appropriate choice.
Each person has the freedom to choose, but must exercise it responsibly, and be
accountable for those choices. Simply making a choice does not imply responsibili-
ty or even accountability. Responsible choices involve awareness - an awareness of
the consequences. One can not become fully accountable for what one does not feel
fully responsible. Ethical choices and decisions need to encompass responsible
choices. Each person needs to be aware and be able to deal with the consequences
of the choices which are made and the consequences of those choices for others in-
volved. Failure to do so is also to deny oneself the freedom to choose responsibly
between rightness and wrongness, between what is valued and what is not valued,
and to be fully accountable for one's decisions.
Freedom also has limitations and one must be aware of" ...one's own freedom
in the act of choosing" [12, p 47]. Choices or decisions need to be based on a ratio-
nale and a process of formal reasoning. But faculty need to make a logical appraisal
[3, p 43] of situations prior to making a decision. Choosing also precedes this rea-
soning, since one can choose whether or not to reason.
In their interactions with students, patients, and with one another, faculty need
to demonstrate consistency - consistency both in beliefs and between actions and
beliefs. Their choices and their behaviors need to be reasonably predictable, reli-
able, and authentic if they are to be role models and effective educators. Values and
decisions need to be integrated into a meaningful, harmonious relationship to en-
sure that consistency. Although no two situations are entirely alike and ethical situa-
tions are characterized more by ambiguity than clarity, consistency between actions
and beliefs is still possible. Faculty do not always agree; in fact at times it seems
they rarely do, and faculty can not respond exactly the same in all situations, but
each person can make similar choices in similar situations.
It is customary, for example, for students to learn communication techniques
and to utilize these in their interactions with patients, faculty, and with one another.
When they do not do so effectively, faculty indicate that their performance is less
than satisfactory. If students were, however, to observe faculty in faculty meetings,
or in one-to-one interactions, frequently it would be the faculty who would receive
the unsatisfactory mark. Under these circumstances, faculty have demonstrated in-
consistency and that they have chosen to value one set of standards for students and
another for themselves.
Perhaps the most basic and relevant assertion is that faculty must be competent,
not only as educators but as practitioners. In order to fully understand the various
alternatives and consequences and in order to assist students to do the same, faculty
need a substantive nursing knowledge base. If students are to view faculty as role
models and learn from the ethical decisions which faculty make, then such compe-
tence is requisite.
Through mutual reciprocity, students and faculty can develop an interdepend-
ent role-modeling process through which each learns from the other. When faculty
and students become able to share their beliefs, their values, their knowledge, and
when they are able to discuss the choices, the potential consequences of choices,
and their responsibilities, each has the opportunity to learn from the other. Each
person brings uniqueness to the situation and provides the other with a personal,
experiential resource and a knowledge base which can be the basis for decision
making and mutual ethical enhancement.
The following situations are examples of ethical dilemmas involved in the teach-
ing of nursing. Each involves questions of responsible choice and focuses on the
patient, the student, or the faculty member as the principle decision maker. Each al-
so has consequences for a variety of other people, who may also need to make
choices. The following three relate to the clinical teaching of nursing.
Situation 1. Mrs. Clearwater, a 19-year-old American Indian, is being admitted to

labor and delivery for the birth of their first child. Although prenatal care was avail-
able in a nearby free clinic, the Clearwaters preferred to follow their own customs
and rituals in preparing for the baby.
Mr. Walker, a 21-year-old male nursing student, is assigned to Mrs. Clearwater.
He is an above-average student but has had some difficulty with his role in labor
and delivery. Although Mr. Walker has been scheduled in labor and delivery for the
past 2 weeks, because of a low census, he has not be able to care for a patient in la-
bor. This is the last day of his rotation. A nursing history and nursing care plan for a
patient in labor are necessary for satisfactory completion of the course require-
ments.
While Mr. Walker is admitting the patient, the assigned physician approaches
the clinical instructor and states, "Mr. Clearwater does not want a male nurse taking
care of his wife. The patient prefers to have her mother present." The physician sim-
ply states that he agrees with the patient and her husband and that he wants the stu-
dent removed from the patient's room.
Situation 2. Mr. Roberts, a 57-year-old male, had a hernia repair early in the morn-
ing. Although his history indicated that he was in excellent health, he developed in-
termittent premature ventricular contractions during the surgical procedure. Fol-
lowing medication, these subsided. He was taken to the recovery room in
satisfactory condition and later transferred to his room.
Mrs. Wilson, a second-year associate degree nursing student, was assigned to
him. The student received report from the recovery room nurse and the team leader.
Routine postoperative orders were written. The patient was attached to a cardiac
monitor as a precautionary measure for observation. The student was instructed to
take the patient's vital signs every 15 miri and report any major changes in the moni-
tor reading.
An hour later, the team leader checked on the patient. He was in acute cardiac
distress and the monitor was disconnected. The student said, "He took off the elec-
trodes. He said he refused to be connected to one of those machines. I explained the
importance of the monitor, but he told me to leave the room. He looked alright and
really insisted, so I left him alone." The patient was transferred to intensive care in
critical condition. The student approached the faculty member and asked how this
would affect her standing in the program.
Situation 3. Miss Barnes is an 18-year-old, unwed mother of two children and is

2 months pregnant. She and her children are regularly seen in the clinics of the local
health department. Both children are current in their immunizations and appear
well nourished and in excellent overall health.
Mrs. Fletcher, a 35-year-old graduate nursing student, is assigned to the client as
a part of her community nursing experience in her major. The student and client
have established an exellent rapport during the two visits Miss Barnes and her chil-
dren have made to the clinic. During the third visit, Miss Barnes indicates she is
considering having an abortion.
Mter trus visit, the student seeks out her clinical instructor and says that since
she (the student) is Catholic, she can no longer continue to work with this client.
Doing so would be in violation of her religious principles and what she believes are
the rights of the fetus. The student asks to be able to select another client so there
would be no conflict with her personal and religious values.
In nonclinical instructional settings, faculty and students face dilemmas of
equal concern. The following two situations are illustrative.
Situation 1. Two masters' prepared faculty are teaching different sections of a

course on nursing thories. They have similar backgrounds and both have taught the
course several times before, but not at the same time. Although the course descrip-
tions and objectives are the same for both sections, assignments are quite differ-
ent.
In the one section, there is a mid-term and final examination as well as a re-
search paper and critique of a major text. In the other section, there is one class-
room presentation and a short paper. The students have complained to the director
of graduate nursing studies and the dean of nursing about the disparities in the re-
quirements. The faculty feel they have the right and the academic freedom to deter-
mine the course content and requirements for their own sections, just as if they were
separate courses. While the director of graduate studies concurs, the dean feels that
the sections should be as similar as possible in order to preserve the rights of the stu-
dents, prepare them for comprehensive examinations, and protect the institution
against liability.
Situation 2. Dr. Larson is an associate professor in nursing with a considerable num-

ber of years in both practice and~teaching. He joined the university 3 years ago and
is now eligible for promotion to full professor. In both the clinical setting and class-
room he is widely respected for his expertise and relates extremely well with stu-
dents. His evaluations by students and the dean have been outstanding.
Dr. Larson is also involved in research and extremely active in political affairs
affecting nursing and the community as a whole. After much research and dialogue,
he has recently taken the stand that it is mandatory that taxes be cut drastically in
order to halt the upward spiral of inflation. This will, however, also mean that the
university will loose a considerable amount of its funding and may even necessitate
the loss of several faculty positions.
His political activities have been sharply criticized by the community, by the ad-
ministration of the institution, and by the faculty. He has been warned that this may
unduly affect his ability to be tenured and promoted.
Feeling the intensity of the controversy and wanting to protect his position, he
takes the issue to his students, requesting their endorsement and active support
against the university and the tenure committee of the school of nursing.
In each of these situations, what choices are available and what are the underly-
ing values inherent in each? What are the consequences of the choices, and what
risks are involved? What is the ethical responsibility of each person, and who is ac-
countable for what? Can there be justice? Does each person involved have the
freedom to make a choice or are values being imposed? How would consistency
be addressed? Are the rights of the persons protected? What choices are respon-
sible?
Although there are a variety of alternatives in these situations, there are no arbi-
trary solutions to the dilemmas. Faculty need to determine the nature of each dilem-
ma and to be aware of the choices which are available. They need to assess the con-
sequences of each alternative as well as the underlying values. To do so responsibly,
each needs to be conversant with acceptable standards and the rights of persons in-
volved. Limitations must be recognized. Risks should be identified and an attempt
should be made to make a choice based on fairness to the individuals involved. This
assumes competence and requires consistency in decision making. Students, when-

ever appropriate, need to be involved in this process so that each can learn from the
others while maintaining each person's freedom of responsible choice. Reflective
reasoning is the foundation for this process and incorporates the mutual trust and
confidence of each person involved.
A variety of other dilemmas in the educational setting could be posed. For ex-
ample, is it ethical to utilize behavioral objectives? Is it ethical to evaluate a stu-
dent's attitudes as a part of the affective domain? What is the ethical responsibility
of faculty regarding the amount of "practice" that students can do on a patient?
What is the ethical responsibility of faculty regarding their credentials for courses
that they teach? Do faculty have an ethical responsibility to prepare graduates for
the roles they will assume upon graduation or for the ones which the faculty feel are
appropriate? Is ethical to admit students to nursing programs when the future of
those programs is uncertain? Are accreditation standards ethical?
Nurse educators have a responsibility not only to the patient and their students
but also to the specific school, college, or university with which each is affiliated.
This responsibility has many facets. Functioning within the political structure of
an educational institution can indeed be challenging. Nursing programs in the
United States are often viewed as high-cost, low-yield programs. Faculty must be
fiscally conscious and willing to assess the consequences of their funding re-
quests and yet mediate tensions generated by their emphasis on quality educa-
tion in view of forces that are less than sensitive to the unique constraints of
nursing education.
Other disciplines within the collegial setting in the United States frequently do
not understand the faculty-student ratios of nursing in the clinical setting. When
there can be 30 students, or even 200, in a history class with one instructor, it can be
difficult for nonnursing faculty to understand why there can not be 200 students, or
even 30, in a clinical nursing class with one instructor. Additionally, some adminis-
trators and faculty do not understand the critical differences between nursing edu-
cation and quality nursing education. In such a dilemma, nursing educators must
represent themselves fairly, and yet be purposefully creative in their approaches
to clinical teaching. They have a responsibility to the student for learning, to the
patient for the provision of safe, effective nursing care, and to the institution to
maintain its viability and integrity. They must be responsible, accountable, and
competent, helping institutional authorities to understand and trust their deci-
sions.
Nursing education, as with any human endeavor, is replete with ethical dilem-
mas. However, nurse educators must set forth a sound, enduring ethical foundation
upon which decisions can be made. Although a code of ethics for nurse educators
has not been formulated, the following one is submitted for your consideration and
as an impetus for dialogue.
A Code of Ethics for Nurse Educators
Preamble
The code of ethics for nurse educators is based on the premise that each person in-
volved in nursing education is unique and has the right to have that uniqueness val-
ued. Nurse educators are responsible for their choices and for adhering to ethical
principles when participating in nursing practice, nursing education, and nursing
research. They have a responsibility for both quality nursing care and effective nurs-
ing education, without discrimination with regard to race, color, religion, socioec-
onomic status, nationality, age, or sex.
1. Nurse educators will assume the responsibility and accountability for their ac-
tions in the practice of nursing and in the education of students.
2. Nurse educators will respect the rights of patients, l students, and colleagues to
exercise freedom of choice.
3. Nurse educators will strive to promote critical thinking, meaningful interactions,
and quality nursing care.
4. Nurse educators will assist the student to become competent in the practice of
nursing and to became responsible ethical decision makers.
5. Nurse educators will maintain the confidentiality of matters relating to each per-
son with whom they have contact.
6. Nurse educators will accept the responsibility for maintaining their own com-
petencies and endeavor to safeguard the patient and the student from the in-
competent.
7. Nurse educators will practice and instruct within the scope of their competen-
cies.
8. Nurse educators will safeguard the rights and dignity of individuals in the prac-
tice of nursing and nursing education.
9. Nurse educators will participate responsibly within the academic setting.
10. Nurse educators will demonstrate respect for the student as a person and as an
interdependent contributor to the profession and to society.
References
1. Archambault R (ed) (1964) John Dewey on education - Selected writings. The University of
Chicago Press, Chicago
2. Barnes H (1967) An existential ethic. Knopf, New York
3. Blackstone W, Newsome G (1969) Education and ethics. University of Georgia Press, Athens,
Georgia
4. Buber M (1965) Between man and man. MacMillan, New York
1 The term patient is used for brevity, but implies patient, client, and/ or significant others
5. Callahan D, Bok S (eds) (1980) Ethics teaching in higher education. Plenum, New York
6. Chazan B, Soltis J (eds) (1975) Moral education. Teachers College Press, New York
7. Curtain L (1978) Nursing ethics: theories and pragmatics. Nurs Forum 17 (1): 4-11
8. Davis A, Aroskar M (1978) Ethical dilemmas and nursing practice. Appleton-Century-Crofts,
New York
9. Edwards T (1953) The new dictionary of thoughts. Standard Book Company, New York
10. Fenner K (1980) Ethics and law in nursing - Professional perspective. Van Nostrand. New York
11. Fromer M (1981) Ethical issues in health care. Mosby, St. Louis
12. Morris VC (1966) Existentialism in education. Harper and Row, New York
13. Peters R (1967) Ethics and education. Scott, Foresman, Atlanta
14. Ryden M (1978) An approach to ethical decision-making. Nurs Outlook 26 (11): 705-712
15. Sigman P (1979) Ethical choice in nursing. Adv Nurs Sci 1 (3): 37-52
16. Sheban J (1965) Mirrors of the soul - Kahlil Gibran. Bantam Books. New York
Social and Role Constraints on Ethical Decision Making
by Nurses in Hospital
A.J.Davis
1 Introduction
In this paper I shall use the words "ethical" and "moral" to mean the same thing.
Ethics or moral philosophy focuses on such concepts as rights, obligations, virtues,
etc. The ethical theories and principles which I use in my thinking and work have
evolved in what is usually called the Western philosophical tradition. This tradition
has benefited from many thinkers such as Plato, Aristotle, Kant, Mill, and many
others. A developed ethical theory provides a framework within which an individu-
al can determine morally appropriate actions. Two such theories that are used by
health professionals are: (a) utilitarianism and (b) deontologic theory. Utilitarian-
ism says that the right depends on the good. That is, what is right is that action
which maximizes the greatest good and least amount of harm for the greatest num-
ber of persons. Deontologic theory says the rightness or wrongness depends on the
nature or form of these actions in terms of their moral significance. There are other
ethical theories, and the two mentioned are far more complex then I have indicated.
I mention them only to indicate that there is a body of knowledge, ethics or moral
philosophy, which can help us to structure the ethical dilemma in order to form a
dialogue and to debate it.
Nursing ethics or health care ethics is applied ethics, in that we take theories and
principles from moral philosophy and apply them to several interrelated areas:
1. clinical,
2. resource allocation,
3. human experimentation, and
4. health policy.
An ethical dilemma is any situation of conflicting moral claims. For example, it's a
situation in which one both ought to do something and ought not do that same
thing. The conflict can be between two moral principles, between patient's rights
and professional's obligation, between one's professional obligation and one's own
values, etc. Ethical dilemmas are complex, but ethical theory can help us to deal
with them in a more systematic way.
Much in the health care ethics or bioethics is written for the physician. This liter-
ature assumes a special type of contractual relationship - historical, social, legal,
ethical - between the patient and the physician. There is a paucity of philosophical
considerations as well as systematic data on ethics of nursing, although the situation
is better than it has been in the recent and distant past.
Ethics as a discipline has several parts. Normative ethics guides the philosophi-
cal considerations because it asks which actions are worthy of moral consideration
and why. Descriptive ethics provides systematic data, since it consists of factual in-
Social and Role Constraints of Ethical Decision Making 161
vestigation of moral beliefs and behavior. My remarks fall into this second category
of descriptive ethics. The code for nurses says that the nurse's first ethical obligation
is to the individual patient. The ethics here are normative ethics. Descriptive ethics
raise questions about whether, to what extent, and under what conditions nurses ac-
tually perform according to their code of ethics. It examines how nurses interpret
their code.
Nurses have multiple ethical obligations. They are obligated to the patient, the
hospital, the physician, and to their own professional code. As long as these obliga-
tions mesh there is no ethical dilemma. However, when what the nurse ought to do
toward one pary conflicts with what she ought to do toward another, then she con-
fronts an ethical dilemma.
I undertook a survey in which I collected data from 205 nurses. The methodolo-
gy was an open-ended questionnaire format. The rationale for this approach was to
have the nurses themselves indicate to what extent they understood the concept of
ethical dilemma and to determine what types of dilemma they confront.
2 The Findings
The majority of the 205 respondents in this survey were young staff nurses who had
a good grasp of the concept of an ethical' dilemma. To the extent that this basic un-
derstanding translates into an articulated ethical stance, these nurses are in a better
position than most to make their ethical concerns known in the two most frequently
occurring dilemmas (prolonging life with heroic measures and unethical/incompe-
tent activity of colleagues) as well as in other ethical dilemmas confronting them.
All participating nurses, regardless of educational background, described the same
types of ethical dilemma, but diploma nurses tended to be more specific in their de-
scription, often limiting it to only clinical issues and especially those immediately
present in their work situation. Diploma nurses indicated that they tended to more
often disagree with physicians on ethical issues than did degree nurses. This may be
due to the fact that diploma nurses had worked longer or it may have something to
do with the specificity of their descriptions. That is, when one focuses over time on
selected ethical issues, one can and does take issue with decisions made. Younger
nurses were more apt to experience difficulties around ethical dilemmas with pat-
ients, families, physicians, and institutions than were older nurses. The reasons for
this remain speculative without further data. Perhaps younger nurses have less in-
vestment in the institution and those people in it than do older nurses or perhaps
they are less "burned out" than older nurses and still have the idealism of youth. Al-
so, of course, it may be that younger nurses do not have as much experience with
these situations and therefore do not perceive them in their multidimensional com-
plexities.
162 A.J.Davis
3 Social and Role Constraints
Davis and Aroskar [1] raised numerous questions regarding the extent to which
nurses in complex health organizations can act as moral agents. Murphy [2] summa-
rizes the situation by saying that a nurse is morally obligated to recognize the rights
of the patient as an individual, but as "an employee in a health care institution she is
often subordinate to the administration and, hence, must uphold the utilitarian
goals of the institution: the greatest good for the greatest number."
When I have conducted ethics rounds with intensive care unit nurses as well as
with other nurses, both in acute and chronic care, it has become apparent to me that
many nurses, although generally aware of the ethical dilemmas confronting them,
remain inarticulate due to their inability to reason ethically and to make their ethi-
cal stance known in a rational manner. The fact that these nurses, often young, fe-
male, and employees in health facilities, present a sentimental or emotional reaction
tends to discredit them and allows others not to take them seriously. This situation
can only make for low morale among staff.
The inability to reason through an ethical dilemma and to present an ethical
stance is one major constraint fOJ: nurses. However, ethical reasoning can be learned
because it depends on a body of knowledge which has been developed.
Another constraint is the nurses' social role in hospitals. And here I limit my re-
marks to the hospital setting, since that is where over 50% of all nurses work.
In examining social roles in hospitals the fact that the majority of the personnel
are women and employees must be considered. Medicine, as a professional group,
dominates the health delivery system. At the same time, however, medicine has be-
come increasingly dependent on these nonphysician groups, referred to by some so-
cial scientists as semiprofessionals, characterized by a lack of strong reference
group orientation to colleagues and therefore without a generalized colleague
group as a source of norrns. This situation can act to maintain the status quo of the
hierarchical order among physicians and other health care personnel, in that these
semiprofessional groups are more willing to accept an administrative superior as
their norm source. Simpson and Simpson [3] believed that this pattern was due to
the prevalence of women in the semiprofessions, who can be characterized as being
more amenable to administrative control, less conscious of organizational status,
and more submissive in this context then men.
Women, socialized in most societies, or at least in patriarchal ones, have histori-
cally been placed in a secondary position. To the extent that this discrimination con-
tinues, it affects social situations in hospitals. These so-called semiprofessionals,
such as nurses, assist the physician in scientific tasks and function to overcome in-
adequacies in the medical scientific method. One way they do this is by preventing
certain information from reaching the patient and his family. Essentially, these se-
miprofessional groups are expected to react with moral passivity to their knowledge
of hospital events. Such expectations can mean that nurses who continue to work in
hospitals are either comfortable with this state of affairs or experience low morale
and burnout. If either is the case, then it is possible that involvement in and concern
about one's own and other's ethical or unethical decisions can easily be viewed as
concerns beyond the call of duty. This can act as a social constraint in ethical deci-
sions. These comments focused on nurses in hospitals are not intended to imply that
Social and Role Constraints of Ethical Decision Making 163
these are evil people interacting with the world in bad faith. They do draw attention
to the fact that given the organizational structure of hospitals, the division of labor
and the hierarchical ordering of personnel, social constraints are built in.
In hospitals when an individual worker or a group comes to grips with an ethical
dilemma, often the risk/benefit ratio comes into play with regards to the formal and
informal reward/punishment system operating in the institution. The major ques-
tion becomes: Can semiprofessional employees, who function within this social
structure as buffers or sponges between the bureaucratic system and the patient, risk
raising ethical issues, especially if they involve those in superordinate positions
within the system? The social structure of the hospital itself is a social constraint.
Emile Durkheim, the French socioligist, makes the point that professionals are
part of a moral community. Social links develop not only to their clients and col-
leagues in their own profession but also to other groups with whose activities their
skills must dovetail. The legitimacy of their contribution, however, must be ac-
knowledged by others. Being labeled "semiprofessional" can inhibit such acknowl-
edgement, can maintain the formal power structure, and can impede vital inter-
change on ethical and other issues central to good health care.
4 Situational Characteristics
In examining the ethical implications of the hierarchically ordered bureaucracy of

the hospital, we can learn from some of the research done in the fields of social psy-
chology and moral development. The research I am referring to was conducted in
the United States, so caution must be used in generalizing to other sociocultural set-
tings. The fact remains, however, that ethical or unethical behavior occurs in a so-
cial context in all cultures.
An important question for us to consider is what factors influence the way we
behave in a moral situation. Although it is sometimes difficult for us to come to
grips with the notion that we are in part creatures of our environment, the difficulty
increases when we examine the idea that some moral behavior is situationally deter-
mined. This is due in part to the fact that our conception of human responsibility is
largely based on the assumption that the individual is responsible for his behavior.
Nevertheless, analysis of the literature to determine whether morality is more
strongly influenced by personality (beliefs, values, attitudes, etc.) than by situations
has had several writers conclude that the latter are far more powerful influences [4,
5]. Nowhere are the data supporting the importance of situational determinants of
moral behavior more compelling than is the reality of and research on the capacity
of people to inflict great harm on others [6].
Clearly, situational characteristics are powerful determinants of how we re-
spond to ethical dilemmas. The fmdings show that the presence of others, the possi-
bility of disapproval, and the awareness of threat (such as loss of job) can inhibit us
from acting. This can serve as a major social constraint for nurses in hospitals given
the hierarchically ordered bureaucracy of that institution. It seems that our ethics or
morality is a complex social phenomenon which is as determined by the character-
istics of the situation in which we find ourselves as by our belief system and our per-
sonality characteristics.
164 A.J. Davis
References
1. Davis AJ, Aroskar M (1978) Ethical dilemmas and nursing practice. Appleton-Century-Crofts,
New York
2. Murphy C (1978) The moral situation in nursing. In: Bandman E, Bandman B (eds) Bioethics
and human rights, Little, Brown, Boston
3. Simpson RL, Simpson IH (1969) Women and bureaucracy in the semiprofessions. In: Etzioni A
(ed) The semi-professions and their organization, Free, New York
4. Moore BS, Underwood B, Rosenhan DL (1973) Affect and altruism. Dev Psychol 8: 99-104
5. Rosenhan DL, Underwood B, Moore BS (1974) Affect moderates selfgratification and altruism, J
Pers Soc Psychol30: 546-52
6. Milgram S (1965) Some considerations of obedience and disobedience to authority. Hum Rela-
tions Feb: 57-75
A Simulation Game: A Tool for Teaching
Ethical Decision Making to Student Nurses in Israel
N.Wagner
The simulation game "Committee on Nursing Ethics" was created to facilitate

teaching student nurses the process of moral and ethical decision making, and to
raise the level of moral judgment. The theoretical framework of this work is the
cognitive-developmental mode of thought as it applies to each individual [4, 6, 7].
Both theorists concern themselves with the problem of growth or change in the area
of moral judgment.
Nursing practice brings the nurse into close and intimate contact with patients
in a variety of settings. This makes her particularly vulnerable to the ethical conflicts
that arise in the course of her daily work. All three kinds of decision-making, depen-
dent, independent, and interdependent, may become conflict-laden for both the
student and the practising nurse. Moreover, new developments in science and tech-
nology affect nursing practices and lead to increasingly personal and professional
value conflicts. For the purpose of training student-nurses in the process of moral
and ethical decision-making, the writer of this work selected the simulation-game
method, under the assumption that games would capture the students' attention
and encourage them to learn more. A simulation game is a structured interaction
among players who operate under an established set of rules to achieve a goal [1, 2].
The simulation game developed by the writer has two basic features:
1. It represents a real-life situation which requires the student-nurse to make an eth-
ical and moral decision.
2. The class is turned into a "Committee on Ethics," which reviews the conduct of a
fellow nurse who was faced with a moral dilemma and acted according to her
judgment.
1 The Game
The class is turned into teams: "committees of ethics." All the participants review
the same incident where a fellow nurse was faced with a moral dilemma and acted
according to her judgment.
2 Equipment
Each team receives a kit which contains:

1. The game instructions
2. The International Council of Nurses Code of Ethics [5]
3. A board with the Star of David representing the decision-making (D-M) model
(Fig: 1)[3]
166 N. Wagner
4. One envelope containing the incident and its outcome on the back (to be placed
in the center of the board) and six triangles which have the judges' answers for
each step of the D-M process on the back. Each player receives a D-M form to be
filled in individually and one for the team's decision. The game is played on three
levels: individual, team, and class.
Analogies
Factual side
Subject - Subject
Fig. 1 Star of David representing the
Subject - Object
decision-making Model
3 Playing the Game
After a general introduction by the teacher of ethics, the purpose of the game, the
rules, and a presentation of the code of ethics, the class is divided into teams of no
more than five members each to ensure active participation and to prevent a silent
audience.
Each of the team reads the same incident and then each player works individu-
ally on the first step.
3.1 Defining the Problem
Most players have difficulties in defining problems. Some summarize the incident,
others write down the course of action. We use the "if - then" method of defining
the dilemma, i. e., to distribute medication or to refuse to distribute medication the
nurse believes might harm the patient. If she will obey the physician's order she
might then do harm.... On the other hand, if she will not, then she may be accused
of interfering with and disobeying the physician's orders.
A Simulation Game: A Tool for Teaching Ethical Decision 167
3.2 ClarifYing Personal and Professional Beliefs
Personal beliefs: each player writes the principles which guide him, for example,
"keeping a promise" or "doing no harm" or "truth telling." Professional beliefs:
each player goes through the code of ethics and looks for guidelines for profession-
al conduct.
If he comes across conflicting concepts he has to comment on them. (The
nurses' primary responsibility is to the patient versus the nurse sustains a coopera-
tive relationship with co-workers.
3.3 Alternatives for Action
Each participant selects a varity of alternatives for action and grades them as good,
average, or bad. This was done to encourage the student to look for additional alter-
natives and to avoid looking for only the conventional, safe one. At this point the
team is asked to compare notes, discuss findings and reasons, and to come to a team
decision., Consensus is not required.
3.4 Decision for Action
The team decides together on a course for action. Then they check the back of the
triangles and discuss their findings with the judges and comment on them.
35 Issues for Discussion
Here the participants write all the issues needed to be discussed in depth, like truth
telling, conflicts of rights, multiple loyalties, and others.
3.6 Generalization and Policy Making
The players are asked to write down other incidents representing the ethical prob-
lem discussed, to broaden their experience. In our opinion, many of the dilemmas
could have been eliminated by correct policies. We encourage the players to suggest
policy guidelines. The time frame for all the above steps is 1 hour. The final 30 min
is dedicated to class discussion that will compare D-M processes and analyze in
depth one or more of the steps or issues discussed above.
At each session a different incident will be played. It is recommended that team
members be changed each game.
168 N.Wagner
4 Evaluation of the Game: Student Comments on the Game
The effectiveness of the simulation game method in teaching ethics was tested in an
experimental study [8].
Sixty-six fIrst-year student nurses from two different nursing schools participat-
ed in the study and were assigned at random to two comparable study groups. The
experimental group used the simulation-game method. The control group learned
by the conventional method: lecture and discussions. Moral judgment was tested
before and after the experiment. Knowledge in ethics and evaluation of teaching
method were tested after the experiment.
The main fmdings of the study indicate fIrst that there is no signillcant differ-
ence in the level of knowledge and relativistic moral judgment of the two groups, al-
though the participants in the game showed a tendency to developing a higher level
of moral judgment than the participants in the conservative teaching group. The
second fInding from the study was that students in the experimental group reported
signifIcantly greater enjoyment in the learning process than those learning through
a conventional method.
Students' comments on the game:
"The class was fun." "It was our class, our input, discussion continued long after
class adjourned." "Every one participated, we listened to each others' ideas and rea-
sons."
"We understand now what ethical behavior is and the use of the code as guide for
professional behavior."
"The written form was evaluated and I could follow my own progress." "I will
never forget the incidents we played." "Through playing the game I feel more pre-
pared to cope with ethical problems in real work settings." "The teacher was a re-
source person and an advisor rather than a preacher."
5 Summary
Today the game is used in schools of nursing and other educational programs in Is-
rael. It should be remembered that the game was developed as a tool to facilitate for
the student nurse the process of ethical decision making and not as an end in itself.
It has to be used intelligently, since even a fun game used repetitively could be bor-
ing.
In conclusion it may be said that student nurses who participated in the game
rated it as a more enjoyable and effective method through which they learned the
moral decision-making process.
References
1. Abt C (1968) Games for learning. In: Boocock S, Child E (eds) Simulation games in learning.
Sage, Beverly Hills, 65-84
2. Abt G (1970) Serious games The Viking Press, New York
A Simulation Game: A Tool for Teaching Ethical Decision 169
3. Bergman R (1973) Ethics - Concepts and practice. Int Nurs Rev 20 (5): 140-41
4. Bull N (1969) Moral education. Routledge & Kegan Paul, London
5. International Council of Nurses (1975) Code for nurses. 22(1)
6. Kohlberg L (1969) State and sequences: the cognitive developmental approach to socialization.
In: Goslin DA (ed) Handbook of socialization theory and research. Rand McNally, Chicago
7. Piaget J (1932) The moral judgement of the child. Routledge & Kagan Paul, London
8. Wagner N (1978) Changes in moral judgement of student nurses as a result of participation in
simulation game. M.A. thesis, Tel Aviv University
Treatment
A Foundation for Nursing Ethics

S.M. Roach
My reflections on caring have evolved primarily from a philosophical and theologi-

cal perspective. The following conceptualization, although tentative, is the result of
these reflections.
1. Caring is an essential human attribute.
2. An individual cares not because he or she is a nurse but because he or she is a
human being.
3. One becomes fulfilled as a human being to the extent that one's caring capacity
is called forth, nurtured, and,appropriately expressed.
4. Caring is not simply an emotional or attitudinal state. It is a total way of being,
of relating, of acting; it is a quality of investment in the other - person, idea, pro-
ject, thing, or self as "other" - in which one expresses self most fully, and
through which one touches most intimately and authentically the core meaning
of human existence.
5. The capacity to care, while almost indestructible, may, nonetheless, be sup-
pressed or repressed when circumstances or events inhibit its growth, and/or
militate against its natural expression.
6. Religious beliefs and theological insights are important in highlighting the mor-
al significance of human actions. The beginnings of nursing were nurtured in
the Judeo-Christian and other religious traditions where caring was seen as a
participation in the life of an all-loving, all compassionate God.
7. Nursing, existing in contemporary society where Judeo-Christian and other reli-
gious values are in sharp tension with a prevailing secularistic and naturalistic
ethic, is calling into question some of its traditional values. One of the values be-
ing challenged is the centrality and professional significance of the concept of
caring.
8. Individuals select nursing as a career because they want to help people.
9. A commitment to nursing, with the satisfaction and fulfillment which it brings,
presupposes the ability and the freedom to care.
10. The human capacity to care is "professionalized" in nursing through the acqui-
sition of those skills - cognitive, affective, and psychomotor - required for the
performance of prescribed nursing functions.
A Foundation for Nursing Ethics 171
11. Caring is "operationalized" in nursing through the specific attributes of compas-

sion, competence, confidence, conscience, and commitment.
12. Caring is not unique to nursing in the sense that it distinguishes nursing from
other disciplines, e. g., medicine or social work. Rather, caring is unique to nurs-
ing in the sense that it is that which uniquely qualifies, as nursing, all the nurse
does in his or her capacity as a nurse. (Caring is not simply the performance of a
task or doing "things:' to people.)
13. Preparation for nursing which seeks to professionalize the student's human ca-
pacity to care and to operationalize caring in ways specific to professional prac-
tice presupposes a nursing curriculum which is holistic and a nursing practice
setting where caring models are visible.
2 Elements of Caring Behavior
As a result of much reflection on caring fiS it is communicated in the behavior of a

nurse, I came up with the following elements, the Five Cs: compassion, compe-
tence, confidence, conscience, commitment. Each of these elements represents a
profile of attitudes, skills, and knowledge. While not mutually exclusive - there is a
sense in which each element presupposes the others - looked at singly, they do serve
to identify some of the specifics of caring behavior.
2.1 Compassion
Compassion is a way of living born out of an awareness of one's relationship to all

living creatures. It engenders a response of participation in the experience of an-
other, a sensitivity to the pain and brokenness of the other. It is a quality of presence
which allows one to share with and make room for the other [7,18].
The word compassion is derived from the Latin paticum, meaning to suffer with,
and it involves us going
...where it hurts, to enter into the places of pain, to share the brokenness, fear,
confusion, and anguish. Compassion challenges us to cry out with those in mis-
ery, to mourn with those who suffer loneliness, to weep with those in tears. Com-
passion requires us to be weak with the weak, vulnerable with the vulnerable and
powerless with the powerless. Compassion means full immersion in the condi-
tion of being human (H.J. M. Nouwen 1980, Compassion, unpublished manu-
script).
Compassion is not a "commercialized" or a "calculated" form of kindness. It is not
simply acquired by skills and techniques. One cannot get a Ph. D. in compassion.
Compassion is more than mere sympathy and emotional attachment: it is born out
of an experience of solidarity with the human family and an identification with the
human condition [18].
172 S. M. Roach
2.2 Competence
Competence is the state of having the knowledge, skills, energy, experience, and
motivation required to respond adequately to the demands of one's professional re-
sponsibilities.
Compassion, which is indispensable to the caring relationship, presupposes and
operates from a competence appropriate to the demands of human care. While
competence without compassion can be brutal and inhumane, compassion without
competence may be no more than a meaningless, if not harmful, intrusion into the
life of a person or persons needing help. The competence we are speaking about in
a caring model of nursing is of a high order. It recognizes knowledge and skill as
power, but a power uncontaminated by the destructiveness of rivalry and competi-
tion.
2.3 Confidence
Confidence is that quality which fosters trusting relationships. We are attuned to the
significance of trusting relationShips in nursing. But we are speaking about a very
special quality of relationships - the kind of confidence which fosters trust without
dependency, communicates truth without violence. It is a confidence which creates
respect without paternalism and ensures a relationship which does not compromise
the freedom and independence of clients by rendering them powerless.
2.4 Conscience
Conscience is a sensitive, informed sense of what is right and wrong, a compass di-
recting one's behavior according to prescribed moral standards.
Professional practice, and I am using the word "practice" in a very general way,
demands a keen ethical and moral sensitivity, an ethical and moral sensitivity which
is the product of disciplined study and reflection. The nurse who "cares" sees the
development of a refined, informed, moral conscience no longer an option, but a
professional responsibility.
2.5 Commitment
Commitment is a complex affective response characterized by a convergence be-

tween one's desires and one's obligations, and by a deliberate choice to act in ac-
cordance with them.
Commitment is a quality of investment of self in a task, a person, choice, or a ca-
reer' a quality which becomes so internalized as a value that what one is obligated to
do is not regarded as a burden. (There is an interesting similarity between Milton
Mayeroffs analysis of caring, particularly his discussion of devotion [17], and
Krathwohl et aI's discussion of the place of commitment as an affective behavior on
a continuum of internalization [12].
3 Caring and Levels of Moral Discourse
In his work, Reason and Conduct, Henry D. Aiken proposes a way of analyzing the
levels at which moral discourse proceeds [1]. Aiken shows that there are at least four
distinctive levels upon which such terms as "good," "right," and "ought" are used,
and he discusses the role of judgment at each of these four levels.
3.1 Moral Discourse Levels
3.1.1 The "Expressive-Evocative" Level
This level refers to the initial response to a situation, such responses including plea-
sure,joy, dislike, etc. "We see something and like it; we hear something and dislike
it; we think of someone and are at once attracted or repelled, we know not why" [1,
p 68]. These expressions, Aiken suggests, serve merely to vent our emotions. They
are conventional expressions of personal feelings. Applying to these reactions such
labels as "good" or "bad" or questioning their truth or validity is decisively inap-
propriate.
3.1.2 The Level of Moral Rules
It is at the level of moral rules that questions about the rightness or wrongness of
certain actions, of what one ought to do in specific situations, begin to be asked.
This level includes two phases, one having to do with statements of fact about
means and consequences involved - the patient ought to have been given accurate
information - and the other identifying the moral rules by which such means and
consequences can be appraised - one ought to tell the truth.
Moral rules, according to Aiken, specify "certain types of behavior which ordi-
nary non-deviant persons within a given community would approve and which de-
mand that the addressee, insofar as he is "normal," likewise approve and, if appro-
priate, act accordingly" [1, p 74-75]. The following are examples of such rules: don't
kill; don't cause pain; don't steal; don't lie; or, stated in positive form, protect life;
relieve suffering; respect the property of others; tell the truth; keep promises.
3.1.3 The Level of Ethical Principles
At this level one questions why a moral rule is right and inquires into the basis for
saying that a particular course of action is indeed right or wrong. At the ethical lev-
el, one considers principles on a higher level of generality than that of moral rules.
They include, for example, such principles as the principle of beneficence - to do
good and prevent harm [8, p45]; the principle of nonmaleficence - to do no harm;
the principle of distributive justice - to treat human beings as equals [8, p 49]; the
sanctity oflife principle - human life is precious, even mysterious, and is worthy of
respect and protection [11, p 18]; the principle of respect for persons - the human
being is of incalculable worth, such worth not determined by utilitarian concerns.
174 S.M.Roach
The role of ethical principles is not to tell us precisely what to do in a particular

case, but rather to provide us with standards for appraising lower-order rules. Ethi-
cal principles function like a compass. They provide for a general direction rather
than the specifics of a road map.
3.1.4 The Post-Ethical or "Human" Level
Aiken suggests that the problem raised at this level is best represented by the ques-
tion, "Why be moral?" There is a fundamental difference between this level and lev-
els two and three. At this fourth level it is as if we were asking questions of morality
which are beyond the functions of morality to answer. But, as Aiken observes, "man
is more if also less than a moral being. And, as such, he may have questions to ask of
morality which it itself is unable to answer" [1, p 85].
3.2 The Caring Paradigm and Aiken ~ wels
I should now like to share a few thoughts on the way in which the proposed ele-
ments of caring - compassion, competence, confidence, conscience, and commit-
ment - may be viewed within the' context of Aiken's levels of moral discourse.
First, in looking at the expressive-evocative level, it is important to remember
that Aiken is saying that judgments about the validity, rightness, or wrongness of
specific reactions at this stage are inappropriate. The reaction a person might have
is merely a reaction, a reflex. When one looks at behavior from a moral and ethical
perspective, however, a reaction at this level does provide cues about the moral de-
mands of a particular situation, as well as about the attitudes and values of the per-
son reacting.
In itself, the initial expressive-evocative reaction to a particular situation com-
municates an ethical and moral sense. In fact, the initial reaction is usually the first
signal that something is not right, that what is happening or has happened does or
does not fit expected moral standards, that a particular situation is consistent or in-
consistent with the moral sensitivities of the one reacting. And, just as a reaction of
noticeable intensity to a particular situation or happening is expressive of an under-
lying value system, so also is no apparent reaction at all. The expressive-evocative
level may be neutral in so far as its objective moral "texture"is concerned; it does,
however, communicate something meaningful about the nature of the situation and
of the response of the person reacting to it.
Although we may not know the "why" of a given response, caring is operative at
the expressive-evocative level. The nature, timing, and intensity of a reaction can be
assumed to be influenced by the quality of one's compassion, the breadth of one's
competence, the nature of one's relationships, the sensitivity of one's conscience,
and the degree and internalization of one's commitments.
Second, when one begins to question a situation and the reaction to it, one goes
beyond the expressive-evocative level, and a more active process of inquiry is ini-
tiated. It is important to interject here, however, that this activity does not take place
in a vacuum. The very questions themselves are shaped by the kind of identification
with the issue or problem, the degree of competence in discerning the significance
of the issues, and the possible approaches which may be used to respond effectively.
The compassionate person rates high on sensitive identification. If he or she does
not have a given level of competence, however, the rating on discernment and ap-
praisal of possible solutions is considerably lower. In fact, the appropriate and criti-
cal questions may not even be raised. Trusting relationships influence the quality of
strategies considered as well as point to the range of options available for planning
outcomes. At this second level, the moral reasoning process is inspired, moved, and
directed by a specific caring stance, with specific affective and cognitive determi-
nants.
At the third level - the level of ethical principles - caring skills take on a sharper
degree of sophistication. In the initial discussion of the elements of caring, namely,
compassion, competence, confidence, conscience, and commitment, it was noted
that these elements are not mutually exclusive. In a sense one element presupposes
the others, supporting the view that an authentic caring response is always some-
how compromised when one of these elements is lacking.
I suggest that there is a sense in which one's unique caring capability influences
the choice of ethical principles one makes in the first place, and certainly modifies
the degree to which one is able to adhere to them. The elements of caring are opera-
tive at both levels, that is, in the discermpent of principles and in the commitment
needed to adhere to them.
One might want to examine how the caring response enters into practical dis-
course pn ethical issues, viewed from different perspectives, for example, from a
utilitarian or formalist position [5, 6, 19].
The process involved at the third level of moral discourse, the level of ethical
principles, reflects in distinct ways the elements of caring. The quality and depth of
compassion and the degree of participation in, and identification with, the situation
involved influence the interpretation one makes of one's obligations - past, present,
future. Competence in understanding the issues; in analyzing significant compo-
nents; and in identifying, morally appraising, and choosing principles also shapes
the position one eventually takes on an issue. These activities, in tum, influence and
are influenced by relationships and by the movement of one's conscience. Commit-
ment to discern, choose, and live by appropriate principles provides the stability
that integrity in the moral life requires.
As indicated above, Aiken suggests that at the fourth, or post-ethical, level we
find ourselves asking questions which are beyond the function of morality to
answer. But Aiken also implies that the questions, nonetheless, are "askable," and
need to be raised. Questions such as "why be moral" (and I would add "why be car-
ing") are in this category.
At the fourth level of moral discourse, the person is drawn into a contemplative
vision of human concerns and moral issues. It is at this level that the rules and prin-
ciples are moved to another perspective of "reasonableness," where contemplative
knowledge, aided, for example, by theological insights and by personal and shared
faith experiences, contributes to the process of ethical decision making.
At this level we are asking the question, "Why be caring at all?" This is a ques-
tion which elicits and draws upon insights on the meaning of human being and on
the relationship of these insights to the meaning of human care. At this level the five
176 S. M. Roach
Cs find their ultimate but seemingly unlimited horizon, immeasurable but compre-
hensible; this horizon is intangible and unquantifiable, but open to, and influenced
by, contemplative vision [3].
The questions "why be moral" and "why be caring" have to do with ultimate
ends and purposes. Perhaps the answer to these questions is "beyond reasoning"
because the answer is already given. The answer is not to be determined: the answer
is to be discovered.
Aristotle says in his Ethics,
We deliberate not about ends but about means to attain ends: no physician delib-
erates whether he should cure, no orator whether he should be convincing, no
statesman whether he should establish law and order, nor does any expert delib-
erate about the end of his profession. We take the end for granted, and then con-
sider in what manner and by what means it can be realized. [2, p 61].
The nurse does not "deliberate" about whether or not she ought to care, for to care
is the end of nursing. She deliberates on how caring can best be accomplished.
4 Conclusion
Caring is living in the context of relational responsibilities. This is really what ethics
is about. Whether we are primarily practitioners of nursing, educators, researchers,
or administrators, our activities involve us in human relationships which imply re-
sponsibility - responsibility to our patients, clients, peers, and colleagues. To the ex-
tent that these relationships are characterized by the qualities of human care, to that
extent are they sensitive to appropriate ethical norms which provide for and ensure
relational responsibility.
Paul Ramsey, a noted contemporary ethicist, speaks ofthese norms as canons of
loyalty, using the biblical notion of fidelity to covenant as the model [24]. Ramsey
considers the moral requirements of medical ethics as only a particular case of the
moral requirements governing the relationships between human beings.
We are born within covenants of life with life. By nature, choice, or need we live
with our fellow men in roles and relations. Therefore we must ask, what is the
meaning of faithfulness of one human being to another in every one of these rela-
tions? This is the ethical question. [24, p XII]
Caring is never simply ajob I must do, and I do not simply "give care." Caring is a
way of being, of relating, and of perceiving my professi,onal responsibilities, and it is
expressed in deliberate actions grounded in appropriate knowledge and learned
skills. Caring is more than an emotional outlook or attitude. It embraces qualities of
mind, breadth of expertise, and determination of will. And it is, in fact, a particular
choice of serving in which I find my own fulfillment.
References
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2. Aristotle (1962) Nichomachean ethics. (Translated by Martin Oswald) The Liberal Arts Press,
Indianapolis
3. Byrne R (1973) Living the contemplative dimension of everyday life. Duquesne University
Press, Pittsburg
4. Carper BA (1979) The ethics of caring. Adv Nurs Sci 1: 11-19
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9. Gaylin W (1979) Caring. Knopf, New York
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McKay, New York
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19. Mill JS (1974) Utilitarianism, on liberty, essay on Bentham. (Edited with introduction by Mary
Warnock) The New American Library Meridian Books, New York
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City
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Fidler memorial lecture. Faculty of Nursing, University of Toronto, Toronto
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lecture. McMaster University School of Nursing, Hamilton
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of Newfoundland. St.John's
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University of Toronto, Toronto
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Papers 3: 40-44
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Ethical Imperatives in Nursing
S. S. Rosario
1 The Importance of the True Concept of the Human Beeing
Personally, I feel that the figure of Florence Nightingale has become greater as I
have become more and more acquainted with her life and her writings. She made
our profession great; not only did she lead it to a total technological reform, but
with her concept of man, she also gave it a magnificent ethical meaning, based on
the natural law. With this contribution, she exalted and protected nursing from the
treat of degradation and servility. I feel, therefore, very united to a woman who
through upright rebelliousness showed us a right way, an extensive and generous
way, in which so many noble options are possible.
Perhaps, at present, these ethics have a bad reputation. The nonethical aspect of
certain positions totally condemns natural ethics and those who believe in these
principles, upholding the right to live. We are accused of being "fanatical zealots of
life." If we demonstrate our convictions through arguments of reason, we are de-
nounced as being "rigid moralists."
In the International Council of Nurses Code for Nurses of 1973, approved in
Mexico, in the section which corresponds to the ethical concepts applied to nursing,
the following is said: "The respect for life, for the dignity and rights of the human
being are essential conditions for nursing."
If nursing wishes to be truly human, it must take into consideration the whole
person. Or, said in another way, so that nursing not lose its substantial qualities, it
must be based on the concept of the being and nature of man. A thorough knowl-
edge of what man is leads us to what is objective. This objective nature of man also
carries with it objective demands, which must be respected. If the concept of man
includes only partial aspects, then one takes as the starting point what the human
person is not, and even with good will the treatment which nursing gives (on this
topic) can become a lamentable error. I do not ignore that perhaps someone will
think that the concept of man as a being composed of matter and spirit with a tran-
scendent destiny is a "prejudice." But what I can assure is that when one has as the
starting point this consideration of the human being, then nursing encounters a val-
ue which ennobles and perfects the person who possesses it, and this consideration
of the human being also explains the conduct of high moral content of so many
consistent professionals engaged in this lofty conception of man. The concept
which each nurse has of man determines his or her moral spirit.
2 Ethical Concepts
Throughout the years, it has become general opinion that the ethical problems of
nursing are very complex and permit diverse and equally valid solutions. This adap-
tation to the ethical pluralism prevailing in a democratic society is such that profes-
Ethical Imperatives in Nursing 179
sionals, who possess an unyielding ftrmness based on a demanding conception of

ethical reality, frequently see themselves labeled as being intransigent for their resis-
tence in collaborating in the permissive practices already admitted as ordinary ad-
ministration in our profession.
Ethics is far from the positivism which tries to reduce it to pure factual content,
void of all absolute normativity. It is also far from the formalism which situates
morality in something perfectly autonomous, based in itself, and independent of
natural ftnality.
The principles and moral norms which ethics indicates have as their source the
rational and free nature of man, such as it appears through the light of reason. The
principal source of ethics is human reason, since it encounters and knows the uni-
versal moral principles, and from certain of these are derived the rest of the princi-
ples of this science.
Therefore, there are three ideas to which attention must be paid:
1. The morality of nursing must be based on being and nature.
2. It must be in conformity with right reason, with ftnality, and be ordered according
to values. Ethics does not live in things, but rather in persons, in their judgments,
in their personality, in their conception and realization of values.
3. Ethics must be rooted in what is trans~endent.
3 The Ethical Formation of Nurses
As has been stated, ethics lives in persons. Ethics as a science has two dimensions:
theoretical and practical. These two should be present in the plan of formation. I
want the need to promote a suitable faculty to be noted, since experience demon-
strates that much more than what is taught, what matters is what is really learned. If
we ask ourselves if our students acquire a total vision of their professional work, it is
possible that we will arrive at conclusions that will make us see as urgent the need to
prepare a faculty of scientiftc and human quality, that will know how to transmit the
ideals of our profession reflecting them in their own person. The basic problem of
any professor of ethics resides in his decision to choose between reductionist doc-
trines and ethics based on natural law.
Ethical principles are also a source of progress in nursing because they prevent
easy solutions; they prompt one to the solution of diffIculties through other ways
distinct from the excessively simple ones of killing, of doing abortions, of sterilizing,
etc. They also prevent nurses from being simple executors of certain orders de-
manded by the patient or by a state or by certain pressure groups. The result of all
this has been that some of us, educators in nursing, feel urged to pay due attention
to the ethical formation of nurses. It is necessary that nurses know how to substan-
tiate with reasons the ethical character of the decisionswhich they make. These de-
cisions may be most varied, because there is a great variety of styles within a rich
and legitimate pluralism. But we do not forget that objective ethics says that there
are problems which admit many solutions, while there are others which demand ad-
aptation to intangible principles.
As a consequence of a well-structured teaching of ethics, topics of research can
180 S. S. Rosario
be posed in the sphere of the decisions of nursing. Thus, far from an immobility, the
ethical science acquired is a source of professional stimulus and progress.
The practical application of ethics is as necessary as the theoretical foundation.
The possession of specific knowledge of this science is a requirement prior to the
real-life situation where it is applied. We should put our students in the real condi-
tions which will make them acquire the habit of doing good. So that this habit be de-
veloped, there must be repetition within nursing practice. For this reason, the fre-
quent experience of practice is unavoidable. This is where the student sees, listens,
and values the actual, individual situation, while he or she learns from the actions of
nursing professionals who are nearby. It is truly the school of life itself which will
make the student incorporate the fundamental attitudes which, by living them,
through others, and among others, make the words of a teacher and the hours of
study more efficient.
With respect to the work atmosphere where our students are preparing them-
selves, so that it really be an educational factor, there must be good organization
and a high degree of planning of the tasks of nursing, close collaboration among its
members, identification of criteria, help within teamwork, and a considerable level
of appreciation for the ethical values in the persons of the nurses.
An example can help us to see this. In the clinic where I work, a 63-year-old pat-
ient was admitted. Seventeen ye,ars prior to this, he had been operated on for a
double aortic lesion. He remained on anticoagulent treatment until the day he was
admitted for a cerebral ictus. He was a farmer.
Upon his admission, the patient was fading, but he would respond correctly to
stimuli and would move his extremities.
During the first 3 days, he remained conscious, but his respiratory status was be-
coming worse and it was necessary to intubate him and use controlled respiration.
On the 4th day, he went into a coma. The nursing care which was applied day
after day was exhaustive and specific for each system. The duration of his coma was
35 days.
The wife remained in the clinic practically the whole time, awaiting news as to
changes in her husband's condition during the day or the night.
Despite moments of natural discouragement due to the constant, grave situation
of the patient, the nurses of the unit put their best effort forward in maintaining the
patient in the best, basic conditions so that he be able to rise above the complica-
tions whenever they presented themselves.
These constant and multiple complications were:
- Acute renal insufficiency, which was treated with peritoneal dialysis. The recu-
peration was total.
- Specific complications of respiratory insufficiency, infection, atelectasis, etc. He
was treated with intubation, tracheotomy, aspirations, artificial respiration. He
totally recuperated.
- Physical incapacity, due to the long period in bed, which was solved through re-
habilitation. At the opportune moment we began to feed him through a nasogas-
tric catheter.
The supervisor of the unit commented to me that all this had entailed a serious ef-
fort for them, but that it had been worthwhile. The patient remained in the hospital
for 91 days.
In a nursing conference, when one examines the case of a patient like this, the
question always arises: "Are we not hoping for the impossible with this patient?"
But there is always the same response: "And if he still responds?" And once again
that voice urges one to fight for the life of another human being.
Human hope needs to encounter in others that profound respect toward nature,
in moments in which one is unarmed, in the hands or in the decisions of doctors and
nurses.
Who could think that the life of this man, with his wife, his children, his work in
the fields, is not something great? Is it not, perhaps, a new chant to life?
It has deeply worried me to see that in the name of a supposed advancement in
the science of nursing, some nursing schools, far from appreciating and transmitting
the ethical foundations of our profession, have eliminated from their programs
everything concerning ethical science. I ask myself: Who is interested in graduating
classes of nurses who will assume work positions without ethical formations? Is it
not possible that many see in ethics a restraint as far as their interests are con-
cerned? Undoubtedly, it is easier to manipulate the decisions of those who lack cri-
teria than of those who have them firmly rooted in their thought and in their con-
duct.
In nursing one frequently professionals who disregard not only the traditional
ethical principles but who also base themselves on the concept that there is nothing
intrinsically good or bad; what is sought is that students of nursing ponder the dis-
tinct alternatives of a moral problem and choose their own system of values, with-
out reference to any moral, objective principles. This leads to relativism, the cause
of grave disorders in nursing.
I am conscious of the fact that moral demands furnish their contribution to what
nursing has produced as best and most beautiful for science, for the individual, and
for society.
4 Legislation and Ethics
What happens when the essence of our profession is trampled on by the laws of
some states which mistreat human rights? What occurs when we are asked for col-
laboration which runs counter to ethical principles?
Human laws, in order to be true laws, must be ordered to the common good and
thus express the natural ordering of the universe. If they contradict that natural or-
der, they are not true laws but rather a corruption of the law and lead to violence
and oppression, no matter how numerous the votes which acclaim them may be.
The number of votes has never determined objective truth. We can consequently say
that if, in effect, the state has an area oflegitimate autonomy to dictate laws and or-
der the citizen's life, that in no way means that it can accomplish this ordering at its
own free interest; on the contrary, it should always proceed taking into account the
necessary reference to natural law.
Much less admissible is the radical form which makes of the state the supreme
source from which all law and right issues. In this way, the simple fact that the state
182 S. S. Rosario
promotes a law as obligatory would suffice to create a right. This is the most total
absolutism. This, in summary, is equivalent to affirming that human law decides
and establishes good and evil, the licit and the illicit at all levels. When morality is
exclusively based on human authority, is sooner or later collapses; it is thus, be-
cause it will be considered as simple convenience and rights will be considered as a
weapon of power.
5 Codes
The deontological codes, the norms which regulate the professional activity of the
nurse, are not an invention of our times. Codes have been accompanying the activi-
ty of the nurse for a considerable number of years, even though throughout the ages
they have been pronounced in a different way.
Some deontological codes, whether they be promulgated in the form of an oath,
a prayer, a treaty, or in the actual form of a code - which are commonly considered
as the most important - reflect within their own sphere some fundamental princi-
ples which have always been recognized by man, although with more or less clarity,
throughout the ages.
The international code and some national ones express in our times this tradi-
tion of codifying norms of conduct for nursing.
But, concretely, in these last few years, we find ourselves with a codification of
norms disassociated from what is transcendent and from natural law, a juridical
positivism that empties some of these codes of any content. The consensus of all
nurses is bought, eliminating the points which may be more conflictive but which
are, on the whole, the ones which demand a strictly deontological solution.
In one way or another, it is highly positive that there be compiled norms which
support what nursing has been and is: a "service to the human race," vis-a-vis the
subjectivism of the nurse who cares for the person, valiently facing the basic prob-
lems, in which the life and other values of the person are brought into play.
But codes are not sufficient; they may be there, but they are in fact ignored in
many cases by the very educators of nursing.
In an age which has discovered the value of conscientious objection, the nurse
has to be encouraged to know how to invoke her conscience against those who pur-
sue others to necessarily collaborate in their immoral plans: a difficult position, but
a valient one. Those who collaborate, those who accept baseness, have an easier life
than those who choose the way of active resistance, but only these preserve the mor-
al recourses which perpetuate the ideal of our nursing.
6 Conclusions
Nursing will last, as such, if, as Frankl says, we are "united through a common will,"
that is, accepting in our task those principal elements which, because they are true
and universal, put our profession at the service of man kind in all its dimensions
and give our professional conduct a transcendent, humanitarian, and scientific
meaning. From all this, one concludes that ethical principles must be present as
something immutable in the formation of new professionals, in each one of us, and
that nursing associations, of whatever type, should be faithful receivers and trans-
mitters. If, on the contrary, we give up in this effort to form right-minded intelli-
gence with wills united in the service of this common meaning, nursing would then
be just another thing not worthwhile being immersed in.
Professional immobilism is excluded if the ethical principles based on natural
law are respected, because each one of them, being intangible, poses a serious chal-
lenge to science, which in the field of nursing, supposes that all the recourses of
which it is capable be brought into play, encouraging it inevitably toward its contin-
ued advancement.
Ethical Considerations in the Care of Dying Patients
L.Hockey
1 Introduction
I would like to explore just one of the many ethical considerations which confront
nurses and other health professionals in the care of dying patients. I have selected
the patient's right to dignity.
My reason for this choice is that I believe it to be one of the most important, if
not the most important, consideration; at the same time, it is one of the least under-
stood, if not the least understood, concept. Moreover, the term "dignity" comes up
regularly in examination answers dealing with the care of the dying and there are
few, if any, textbooks which do not make reference to the need to preserve the pat-
ient's dignity. My paper is structured around three questions:
1. What is dignity?
2. Do patients have a right to dignity?
3. Are dying patients different with regard to this right and, if so, in what way?
I recognize these questions as ethical ones; but I am not a moral philosopher myself
and I hope that I will get some clarification from people who are better qualified
than I am.
2 The First Question Is: What is Dignity?
The term dignity, as I have already mentioned, occurs frequently but is hardly ever
defined. The dictionary gives pointers but does not provide a clear-cut definition.
Dignity has to do with "worth" and with "respect." Within the context of patient
care I would paraphrase "preserving the patient's dignity" by "showing the patient
respect in the awareness of his individual worth." It includes the encouragement of
self-respect; it is the preservation of the patient's integrity as a "whole" human be-
ing, including his past and anticipated future which are part of him, and including
also his relationships with significant others. The thesaurus of synonyms and ant-
onyms gives some color to the term dignity by defining its opposite as "degrada-
tion" and the opposite to showing dignity as "undervaluing." Thus, if I do not pre-
serve a patient's dignity in the course of my care, I degrade and undervalue him.
Putting the matter in this form seems to make it immediately desirable to preserve
dignity. Yes, we ought to, it is good; it is right. Our conduct as nurses should be di-
rected by it. What is the force which directs us to conduct ourselves in this way? It is
neither pure science nor pure emotion; it is a composite force; physical and behav-
ioral sciences must play an important part, and also ideological considerations
which may have their origin in religion, in politics, or in other sources of value sys-
tems. However, ultimately the force is activated by a moral judgment, by the notion
of obligation, and it is moral philosophy or ethics which should be able to help to
Ethical Considerations in the Care of Dying Patients 185
provide an analysis of these fundamental concepts. While ethical considerations

alone cannot dictate or prescribe our conduct, they make an important contribu-
tion. They are a necessary, though not a sufficient, condition for the study and the
understanding of human conduct in the care of patients.
3 The Second Question: Do Patients Have a Right to Dignity?
To some extent this question has already been answered, albeit in an oblique way.
Before addressing it more directly, the term "right" requires some clarification.
Again, moral philosophy should and can help, as long as we do not refer to legal
rights alone. The right to dignity is not a legal right; it is not explicit in any legal
code, at least not expressed in this way. The boundary between legal and ethical
concerns is, however, blurred.
In relation to dignity, the distinction between a legal and a moral right to it de-
pends on what one considers to be components of dignity. For example, if dignity
includes the right to reject treatment, the doctor's legal duty to provide treatment
may be iti conflict; the converse may apply with an equal conflict between a legal
and moral right. Thus, the patient with his legal right to treatment may be consid-
ered by a physician as a person whose treatment would be morally indefensible.
What is a right? Having looked at many expositions of the term in the literature,
I decided to fall back on Ginsberg who wrote On Justice in Society [1] nearly
20 years ago:
A right may be defined as a claim that is or can be justly made by or on behalf of
an individual or group to some condition or power.
In our case it is the claw to respect by others or self. Ginsberg goes on to say:
Distinct rights and duties are based on distinct elements of well-being.
He explains the inclusion of the words "on behalf of' in the definition to cover
cases in which the subjects of the rights have not the capacity to make a claim. Gins-
berg understandably links rights and duties, saying that they rest on the same ethical
foundation.
A person's right consists of his claims to the conditions of well-being; his duties
of what he is expected to contribute to well-being.
It is the linking of rights with duties that takes us into the area of justice. The World
Health Organization's target of access to health care for all by the year 2000, which
arose from the Alma Ata Conference, clearly has in implication for the ethical rights
of nations and individuals within nations; it is a target which appeals to justice in
the world.
Yes, patients do have a right to dignity as part of their contract with professional
carers.
186 L. Hockey
4 The Third Question: Are Dying Patients Different with Regard to This Right?
My last question relates to the care of dying patients and asks whether these pat-
ients are different from others in relation to their right to dignity and, if so, in what
way.
The definition of dying has exercised many people, scientists, and the caring
professions for many years. The purist could argue that dying begins at birth. I de-
liberately refrain from using terminal illness or terminal patient because life itself is
a terminal condition which carries a 100% mortality. However, for the purpose of
our disctlssion it is important to arrive at some agreed interpretation of "dying." As
professionals we are probably fairly able to recognize the beginning of the end but
less able to give it valid or reliable descriptors. I am not attempting to do that either
and apologize for the crude and elementary proposition that a dying patient is one
who is not expected to benefit from therapeutic intervention.
Are these patients different from any others as far as their right to dignity is con-
cerned? Detached from the actual caring situation we would probably agree that
dying patients have exactly the same rights as others; we would, moreover, agree
that the dignity of dying patientS' is more readily damaged and that it is, therefore,
especially important to build safeguards into their care. What makes them different?
Going back to Ginsberg's [1] explanation of a right and its alignment to duties, a
dying patient may not be able to perform his duty any longer. Can we allow rights
without responsibilities and duties? Is it just to allow it? I defmed dignity as having
individual worth and self-respect. Does a dying patient have as much worth as a
person with a future? We all know the extent to which a person's expected contribu-
tion to the national economy forms an important part of cost-benefit calculations?
A dying person will make no contribution; what is his worth?
To demonstrate respect for a dying patient or to encourage his self-respect is
time consuming. If a choice has to be made between giving time to a young person
with a serious illness, which is expected to respond to treatment, and an elderly dy-
ing person, is it perhaps right to invest this precious commodity of time in the care
of the former rather than the latter? Research has demonstrated the many symp-
toms of dying patients which interfere with their dignity: incontinence, bad smell,
excessive pain, inability to keep themselves groomed - to mention just a few. They
can all be alleviated but at the cost of time.
It is also important to consider the family. Assault on the patient's dignity affects
the family profoundly, and if their dignity is offended they are not able to function
as individuals of worth, giving support to the dying person and sustaining their own
equilibrium.
In answer to the questions I posed, dying patients are different in that they can
no longer perform duties to balance their rights. Special effort must be made to pay
more than lip service to dignity.
The most important difference between dying patients and others is the unique-
ness of the dying experience. Assaults on dignity cannot be reversed; mistakes can-
not be corrected.
The question I have often been asked by students is how one can preserve the
dignity of a patient against so many uncontrollable odds. Let me give you an exam-
ple of what in ingenious nurse did for an old lady with a colostomy for malignancy.
Ethical Considerations in the Care of Dying Patients 187
This patient said:

When I went into hospital I was a dirty old woman, I couldn't keep myself clean
and my daughter was always angry with me. I was sick of myself and didn't care
any more what happened. The nurses in hospital were so lovely and when they
taught me how to clean myself up one of them said : "You see, the doctors turned
your back passage round so you can see what you are doing. It's hard for an eld-
erly person to clean herself after the toilet - this will be easier for you. We know
you are so particular."
Her self-respect had been totally restored and the daughter was delighted. Although
a novel way of introducing a patient to a colostomy, this was, in my view, a superb
demonstration of the possibility of restoring self-respect and dignity.
In closing, I want to make two points and to raise two questions for discussion.
I have already alluded to my first point, that of time. Dying patients are very
time consuming as far as nursing is concerned. Many of them are comatose and
they are, after all, dying anyway. In view of the pressures in a busy ward, is it not
right to give more time to the patients whom we want to cure?
My second point: dying patients are likely to have unpleasant and often repul-
sive symptoms. They cannot complain and, as their dying experience is unique, they
cannot compare their care with anythiqg else.
The care givers, such as the nurses, are human beings and may be repulsed by
the patient's condition and symptoms. Depressed, confused, incontinent, smelly
patients are not the most attractive subjects for care. It is only too easy to show one's
repulsion, thereby often hurting the patient; it is also easy to reduce contact with the
patient using 101 rationalizations for doing it. It is an assault to dignity.
The only force which keeps one going on and doing what one knows to be right
is a sense of value or moral duty. My questions are: can such values be inculcated in
training or should only people holding these values be recruited? What is the test
anyway?
Related to this question is the following: do you think that people holding high
moral values select themselves for the caring professions? I thought so until some
research by Reid [2], based on observational data, showed incontinent patients be-
ing cleaned up with the aid of long-handled brushes. Perhaps the grimness of the
reality outweighs the appeal of the abstract vocation.
The significance of this example lies in the withholding of one of the most effec-
tive and valuable tools a nurse has at her disposal; I refer to "touch." The patients in
this instance were "untouchables" and the nurse removed herself from them literal-
ly. Are there any other tolls, abilities, skills, is there anything else that we deliberate-
ly or unwittingly withhold from our patients? Do we remove ourselves in any way
from those for whom we profess to care? Do we deny them knowledge, empathy,
compassion? What do you think?
References
1. Ginsberg M (1965) On justice in society. Penguin, Harmondsworth

2. Reid E (1975) Incontinence in nursing practice: an investigation of the nursing management of
soiling in non-bedfast patients. Ph. D. thesis, University of Edinburgh
Ethical Problems in the Assessment of the Quality of Care
R. Eldar
The assessment of the quality of care aims to determine whether acceptable care is
being provided. It relies on three types of information about the care - its structure,
its process, and its outcome - and may be approached by studying anyone of these
three elements.
The approach of structure assumes that better quality of care is more likely to be
provided when better qualified staff, improved physical facilities, and a sounder ad-
ministrative organization exist. This approach evaluates the inputs of human and
material resources available and the way in which these are organized. It entails
studies of the institution's staff; its physical plant, equipment, supplies, and budget;
and its organizational features.
The process approach examines how resources are being utilized and assesses
whether the technical management of patients and the interpersonal interaction be-
tween health professionals and patients conforms with accepted principles and
practices. This approach involves ,studies of the activities of practitioners as well as
studies of the volume of care, the way in which ancillary services are being used,
and the patterns of care.
The study of outcome addresses the output or end results toward which the re-
sources have been used. It entails the evaluation of changes in the current and fu-
ture health status attributable to antecedent care. It examines morbidity, mortality,
recovery, and survival rates and measurements that reflect the restoration of func-
tion physical, physiological, psychological, and social). It also involves the apprais-
al of patient attitudes, such as satisfaction, health-related knowledge, and health-re-
lated behavioral change acquired by patients.
This threefold approach to the assessment of quality is possible because there is
a fundamental, functional relationship among the three elements: structural charac-
teristics of the setting in which care takes place affect the process of care, and
changes in the process of care influence the effect of care on health status. Any of
the three elements of care may be studied, singly or in combination, provided there
is a valid relation between them and the quality of care in the given case. The selec-
tion of the element studied depends on which of its criteria and standards can more
easily and more accurately be measured in the specific situation.
The element of structure, being rather stable, indicates only general tendencies
and is not used as a tool of continuous surveillance. The approaches of process and
outcome are the ones in common use for this purpose, and they appear to be equal-
ly valid in most cases. However, in both approaches ethical problems may arise.
In the process approach, the technical management of the case is based on
norms that derive from the state of science and technology and are determined by
health practitioners who also generate and control the information needed to assess
them. The interpersonal interaction, on the other hand, is determined by norms that
derive from the values and ethical principles that govern, in a given society, relation-
ships among people in general and between health practitioners and patients in par-
Ethical Problems in the Assessment of the Quality of Care 189
ticular. These norms can be assessed by patients, who are also sources of criteria,
standards, and information of this component of the process of care. Process can be
assessed prospectively, concurrently, or retrospectively for preventive, interventive,
or remedial purposes respectively. In any case, ethical problems may appear. These
can arise from the inclusion of procedures that are still in an experimental stage or
from withholding care that is generally viewed to be useful, even when there may be
no cinvincing evidence to support this view. The incorporation of insufficiently vali-
dated prevalent practices as formal criteria and standards into an assessment pro-
gram may lead to the perpetuation of possible errors on the basis of ethical consid-
erations. Once established, such practices are not only less likely to be questioned,
but it may become impossible to subject them to testing under experimental condi-
tions.
Outcome assessments may include appraisal of immediate or intermediate ele-
ments in the chain of results during the provision of care. However, in most cases,
the assessment of outcome is retrospective. It may be attempted so early that the re-
sults are not yet fully known, or so late that they have lost some of their usefulness.
Adverse outcomes that are delayed raise an ethical problem of not intervening earli-
er to prevent such outcomes. If these can be predicted with reasonable certainty by
a timely examination of process, it would not be ethical not to do so. Intervention
after the event may avoid or minimize the, future incidence of such outcomes, but in
the meantime an unjustifiable amount of potentially preventable harm may have
been done. The outcome approach enables the patient to be the primary source of
information only regarding the results expressed in functional terms. However, the
results of fine distinctions in physiological, biochemical, and functional state are
defined, specified, and measured by experts. The assessment of outcomes will give
not information about the acceptability to the patient of the manner in which the re-
sults have been attained, unless specific aspects of patient satisfaction are included
among the measured outcomes.
Thus, both approaches in common use for the assessment of the quality of care
and its assurance - the process approach and the outcome approach - may give rise
to ethical problems. The ethical issues raised differ, however, depending on the ap-
proach used. There also is a difference among the approaches as to the extent to
which patients are sources of information used for the determination of criteria and
standards of data needed for their assessment. These differences may affect social
policy considerations that pertain to the choice of an appropriate definition and lev-
el of quality. The practical implication of the differing ethical vulnerability of the
two approaches for the formulation of these aspects of social policy lies in the possi-
bility that inequities can arise if process criteria are used to assess the quality of
care - and its assurance - received by certain population groups in a specific situa-
tion, while outcome criteria are used for other groups in the same situation. Thus,
for example, outcome criteria in quality assessment and assurance have been used
with the aim of controlling the costs of care. Accordingly, there may be pressure that
organizations that are subsidized partly or wholly by public funds rely more on
measures of outcome rather than on measures of process. If this happens, care
available to people dependent on these sources of care will be of lower quality than
the care provided for the same condition by another population group obtaining its
care at another source. This is because services that are generally considered to be
190 R.Eldar
useful could be withheld under the pretext that they are not sufficiently validated or
because outcome criteria were set rather low or because some outcomes may not be
measured at all.
In order to minimize the influence of ethical issues arising from the assessment
of the quality of care on the formulation of social policy regarding the definition of
quality of care and its level, it is suggested that the same approach be used to assess
the quality of care in a given condition provided to different population groups.
Ethical Issues in the Care of the Elderly
Under Socialised Medicine
M. S. Macmillan
1 Introduction
I have chosen to address the subject of Ethical issues in the care of the elderly under
socialized medicine for several reasons. The area of medical ethics has long been a
personal interest and I am presently attached to the Edinburgh Medical Group,
whose raison d'etre is to discuss such topics on an interdisciplinary basis. Care of
the elderly is of universal interest to those of us not in the first flush of youth and it
is the subject of my current research. As for nationalized medicine, it is the system
I've been brought up with and under whose aegis I have worked and under whose
care I've been treated.
2 Background
It might be of interest to know that the National Health Service (NHS) was finally
brought into being in 1949 [6] as part of the response to Aneurin Bevan's "5 Giants,"
which were:
1. Poverty, which was to be answered by social security, insurance, and pensions
2. Squalor, which was to be answered by a new housing policy
3. Disease, which was to be answered by the NHS
4. Indolence, which was to be answered by eradication of unemployment
5. Ignorance, which was to be answered by a new education policy
Our health service is a mixed system where the state provides health services for all
and the costs are met by taxation and compulsory contributions, but those who wish
to may pay for private care. While it is true that there is a service provided for all, it
is also true that not all patients are treated identically.
This NHS is provided in Scotland for a population of around 5.2 million [7]
which has had only minor fluctuations since 1961 and no significant change is ex-
pected up to 1991. The most important population change is the rise in the number
of people of 65 years and over. In the next 15 years, those aged 75-84 will have in-
creased by 18.7% and those aged 85 and over by 47.2%. However, it must be noted
that this group will only number some 61000. 1 This weighting of elderly people
does, of course, have implications for the provision not only of acute health care but
also for an increased demand for long-term care, particularly of geriatric and psy-
chogeriatric hospital places, and also community services such as district nurses
and health visitors as well as general practitioners.
1 Registrar General Scotland, projected home population, 1977-based and unpublished figures
192 M.S.Macmillan
My present research is designed to find out what information is collected about

patients aged 75 and over and how it is handled to facilitate their movement be-
tween hospital and the community for an acute episode of illness. I am gathering
data by conducting informal interviews with nurses - nursing officers, ward sisters,
staff nurses, and enrolled nurses - in general medical and surgical wards in a hospi-
tal in Edinburgh. Very soon I shall interview a group of patients of the appropriate
age to hear what their views are on the subject. Unfortunately, the analysis of these
data is at an early stage, and though I will use them, it will be in a tentative way.
3 Are There Etbicallssues?
As in most relatively stable societies, we have a long heritage of law and customs
which are the outcome and demonstration of our commonly held moral views.
However, these views have and, to a greater or lesser extent, are being challenged by
social change. I think it behooves nurses to examine these, both the long-held as-
s!lmptions and the changing mores, and come to decisions about how they are go-
ing to behave as people and as nurses. From our census and from Registrars' infor-
mation [2, 5], it is clear that there are considerable changes. These include changed
fertility patterns, increasing socioeconomic and geographical mobility, rising di-
vorce rate, increasing numbers of women in employment, and increased longevity.
Traditionally, it has been the family that has looked after its own elderly members.
But increasing numbers of elderly people, particularly of old ladies, many of whom
never married (a legacy of two world wars), as well as "retired" daughters looking
after aged mothers, make for a need to look again at how we do look after the elder-
ly and how we ought to provide care. Surely there are inherent problems which re-
quire ethical decisions.
4 How Do We Think About Etbicallssues?
Within the compass of this short paper I cannot give a detailed exposition of the
various theories that have been used to arrive at ethical decisions.
One of the long-held theories that comes from our Judeo-Christian tradition as
well as that of the Stoics is that there are positive principles of right and wrong.
However, there is a distinction to be made between moral rules which are specific
and concrete, like the Ten Commandments, and principles that are more general
and abstract. Kant's formula of "Act only on the maxim through which you can at
the same time will that it should become a universal law" [3], suggests the idea of
"universalizability," i. e., in terms of more general and abstract principles the conse-
quences of everyone's acting in a certain way must not be undesirable.
If one accepts that ethical judgments must be made from a universal point of
view and one's own interests can't count for more than any other person's, then as
Singer [9] has argued:
.. .I have to take account of the interests of all those affected by my decision. This
requires me to weigh up all those interests and adopt the course of action most
Ethical Issues in the Care of the Elderly under Socialised Medicine 193
likely to maximise the interests of those affected. Thus, I must choose the course
of action which has the best consequences, on balance, for all affected. This is a
form of utilitarianism.
This, then, would seem to show a means of weighing the preferences or desires of
other people, but perhaps here we'd want to introduce the concept of rights. By
rights I mean more fundamental moral considerations than preferences or desires
which can be violated. I have chosen rights because I see them as being responded
to by responsibilities. The consideration of these I have found as a way of raising
the ethical issues. Though I will suggest three pairs of what I've chosen to call rights
and responsibilities, I make no claim to them being comprehensive or even most im-
portant. They are merely interesting.
5 Rights and Responsibilities
5.1 Rights and Responsibilities ofthe State
Firstly, I would suggest the state has a right to use resources which is responded to
by the responsibility to provide services.
What I mean is that I believe that the state has a right to make use of the skill,
energy, time, and money that is inherent in its people and land. When thinking
about the National Health Service, I contend that the state has a right to use the
skill, energy, and time of the doctors and nurses as well as others to operate the sys-
tem. Clearly, this right can be violated by doctors and nurses or others deciding to
withhold their labor or prevent others from giving theirs, or doctors and nurses giv-
ing labor only to the private sector. However, if the state does have this right, it must
respond by exhibiting responsibility in the form of providing complete health ser-
vices for all or as many of the citizens as wish to avail themselves of such a service.
Secondly, I suggest that the state has a right to improve its resources, but that is
responded to by accepting the responsibility to employ democratic division of re-
sources. I would defend the right to improve resources by means of allowing doc-
tors to pursue research and techniques in a chosen specialty, for example, the fund-
ing of heart transplant units, and thereby extend the frontiers of knowledge and
skill. However, that has got to be responded to by the responsibility to listen to the
democratic arguments as to how these expensive resources should be divided. How
else does one carve up the "national cake" between the cardiologist and the geriatri-
cian? I am no expert in the intricacies of resource allocation, though there are those
who are knowledgeable [1].
Thirdly, the state has a right to knowledge about its people and resources which
it gains by means of a decennial census and the filling in of what sometimes seem to
be interminable forms of one sort or another, but this means that we do know how
many of us there are and what sort of procedures are being done and where. The
state, in response to that right to knowledge, has a responsibility to use that informa-
tion in a reasonable manner. There is the inherent need for confidentiality for the in-
dividual. However, I believe that such information ought to be used to develop for-
194 M. S. Macmillan
ward planning [8], otherwise it would be possible to go on providing services that

were no longer needed just because it had "aye been done."
5.2 Rights and Responsibilities ofthe Nurse
Firstly, I suggest the nurse has a right to be an individual but this is responded to by
a responsibility to see patients as individuals. I think it can be difficult for nurses to
maintain their individuality; for one thing they are all in uniform. Certainly, they
will confess to hiding behind it, though sometimes they see that es being a great ad-'
vantage! Too, with the nursing hierarchical structure there is great pressure to be
good and fit in to one's appointed role. Nurses are an incredibly acquiescing group
of workers, though perhaps they are becoming rather less so. An attempt to accept
the responsibility to see patients as individuals is being tried by adopting the "nurs-
ing process," but often that seems too mechanistic to be really individual. The reten-
tion of the nurse's individuality, with an her past, ought to enhance her imaginative
seeing of individual elderly patients, who may, for example, be deaf or have differ-
ent demands in the degree of formality in modes of address or a different sense of
humor.
Secondly, I would contend that a nurse has a right to withhold care but this must
be balanced by the responsibility to behave in a professional way. By withholding
care, I am not advocating cruelty or negligence but rather the acceptance that each
nurse cannot like all patients equally, nor can she accept the total hurt of each pat-
ient. If she did she very soon would be of little use to anyone, least of all herself~
However, this right must be responded to by accepting the responsibility to care for
all patients in her charge. It may mean that though she personally withholds care,
she will be committed to finding someone, perhaps like a minister or another nurse
or social worker, who can profoundly "hear" the patient.
Thirdly, the nurse has a right to obtain information about patients which is
answered by the responsibility to preserve confidentiality and perhaps to withhold
information. Certainly, my data reveal that this right nurses totally accept and they
also seem to think that they can gather it by whatever means comes to hand, and
they have no qualms about checking its validity in the sense that they are quite li-
able to ask the patient, then relatives, and possibly others to check the story. They
see this as being of great importance when dealing with the elderly, for they see the
patients as not always being totally honest. However, I'm not sure that they really
appreciate that shared information makes one vulnerable to the power of informa-
tion and old people are specially sensitive to such a threat.
5.3 Rights and Responsibilities ofthe Patient
Firstly, like nurses, patients have a right to be individuals which must be responded
to by the responsibility to cooperate. For elderly people, it is hugely important to re-
main individuals. It is this that retains their dignity and wholeness as people. How-
ever, they have a responsibility to cooperate when they are in a setting of shared
space and resources, often a very trying and distressing experience.
Ethical Issues in the Care of the Elderly under Socialised Medicine 195
Secondly, I think that old people have a right to be dependent but they have a
responsibility to be strong. I mean by that that when, by virtue of the aging process,
they are tired and frail then their dependence must have no stigma attached to it.
This dependence does not necessarily indicate a return to childlike dependence
with its inability to make decisions for oneself. But the responsibility to be strong
means that they must ask for the services as they want them. They must not be fear-
ful to ask doctors or nurses for information. Nor should they be fearful in demand-
ing to be taken seriously.
In the third place, elderly patients have a right to knowledge about treatment
and prognosis as well as diagnosis. The responding responsibility is the proper use
of that knowledge. Such elderly patients are vulnerable to the assumption, on the
part of nurses, that they are too frail or confused to be burdened with such knowl-
edge. It may well be a demanding process to make sure that patients fully under-
stand the information that they have a right to hold. The responsibility of the proper
use of knowledge can be difficult for patients to bear if, for example, it involves ac-
ceptance of inabilities or the need to change a way of life or habits.
6 Conclusions
I hope that I have been able to indicate a little of the relationship between what I
have called rights and responsibilities. Certainly, I believe that neither are absolute
because each one is subject to limitation by other rights and responsibilities due ei-
ther to the same person or to others. The Rroper tension among all these rights and
responsibilities is often difficult to maintain. How, if the pendulum has swung too
far in one direction, that can be effected and affected I'm not sure. But it is this very
point that is part of the defense for thinking about ethical issues.
Jenny Joseph has summed this up well in her poem "Warning" [4]:
When I am an old woman I shall wear purple
With a red hat which doesn't go, and doesn't suit me,
And I shall spend my pension on brandy and summer gloves
And satin sandals, and say we've no money for butter,
I shall sit down on the pavement when I'm tired
And gobble up samples in shops and press alarm bells
And run my stick along the public railings
And make up for the sobriety of my youth.
I shall go out in my slippers in the rain
And pick the flowers in other people's gardens
And learn to spit.
You can wear terrible shirts and grow more fat
And eat three pounds of sausages at a go
Or only bread and pickles for a week
And hoard pens and pencils and beermats and things in boxes.
But now we must have clothes that keep us dry
And pay our rent and not swear in the street
And set a good example for the children.
196 M.S.Macmillan
We will have friends to dinner and read the papers.

But maybe I ought to practice a little now?
So people who know me are not too shocked and surprised
When suddenly I am old and start to wear purple.
I would commend her question, "But maybe I ought to practice a little now?"
References
1. Boyd KM (1979) The ethics of resource allocation in health care. Edinburgh University Press,
Edinburgh
2. Cox PR (1976) Demography, 5th ed. Cambridge University Press, Cambridge
3. Hare RM (1952) Language of morals. Clarendon, Oxford
4. Larkin Philip (ed) (1973) The Oxford book of twentieth century verse. Oxford University Press,
Oxford
5. Office of Population Censuses and Surveys (1971, 1981) Census 1971, 1981. HMSO, London
6. Pater JE (1981) The making of the National Health Service. King's Fund, London
7. Scottish Health Service Planning Council (1980) Scottish Health Authorities priorities for the
eighties. HMSO, Edinburgh
8. Shegog RFA (ed) (1981) The impending crisis of old age - A challenge to ingenuity. Oxford Uni-
versity Press, Oxford
9. Singer P (1979) Practical ethics. Cambridge University Press, Cambridge
Feeding Problems
K. Asplund and A. Norberg
In this paper, we wish to present a hypothesis about the care workers reactions to
the feeding problems of the old, demented patient in the terminal phase of life.
The hypothesis is formulated on the basis of taped group discussions with care
workers in four long-term care wards over a 2-year, period, interviews with experts,
interviews with 200 nurses aides and enrolled nurses in 22 nursing homes, and ob-
servations in long-term care wards over a 3-year period.
Our hypothesis is that the situation for the care workers can be interpreted as a
double bind. The care workers feel conflicting demands. On one hand, one must
keep the patient alive, or at least one must not shorten the patient's life. In this phase,
spoon-feeding cannot keep the patient alive. He often does not understand how to
eat or want to eat. He sometimes is not able to eat. Intravenous infusions cannot
keep the patient alive for more than a few weeks. The veins are brittle. By subcu-
taneous infusions the patient cannot be kypt alive. He will starve to death. Nasogas-
tric tube-feeding is the most effective means of keeping the patient alive.
On the other hand, one must not cause the patient pOintless suffering. The patient
is hurt when he is spoon-fed. He shows panic. He swallows the wrong way. But the
patient is hurt when he is fed by infusions. This patient has been fed by infusions for
a month. What was the meaning of this last month from the patient's point of view?
The patient is hurt as well when he is fed by tube. He is bent like a fetus and has no
mental contact with the care workers. It is hard to avoid decubital ulcers and gan-
grene. If you do not like to feed the patient by spoon, infusion, or tube then you can
let him die from water deficiency. Does the patient then suffer from thirst?
If one must keep the patient alive and not cause the patient pointless suffering,
still one must not force the patient. Care workers feel that the last spoon-feeding is
forced feeding. The nurse has to open the patient's mouth and force him to swallow.
The patient may try to defend himself against the infusion or the tube. He removes
it. The nurse may have to bind the patient's hands. The nurse feels she forces the
patient. In this situation the care workers feel that whatever they do, they do the
wrong thing. It is wrong to use forced spoon-feeding. It is wrong to use infusions
and tubes. It is wrong to let the patient die from lack of water. If everything you are
doing is wrong, you need to talk it over with your co-workers, but sometimes this is
forbidden.
In addition to the three previously mentioned conflicting demands, one must not
meta-communicate. One must not talk about death, suffering, and force. Sometimes
one must not even think about it. The care workers behave as if they were unaware
of the problem. But their anxiety is easily provoked. If whatever you are doing is
wrong and you are not allowed to talk about it then a normal reaction is to escape.
You avoid the ward and if this is not possible you avoid the patient.
But sometimes it is not possible to escape. When cleaning the patient, the nurse's
aide has to see the patient, smell him, listen to him, touch him. The physician, for
example, may have to make a decision about the .feeding situation.
198 K.Asplund and A. Norberg
These persons who feel conflicting demands, cannot meta-communicate, and

cannot escape are in a double-bind situation.
Now I wish to put forward two questions:
1. What are the consequences of the double-bind situation for the care of the pat-
ient?
2. How can the double bind be resolved?
When everything you are doing is wrong, you feel guilty. You defend yourself
against guilt by using the defense mechanisms of the ego. There are many defense
mechanisms and combinations of defense mechanisms.
Distancing is probably the first consequence. The nurse says to herself, "This is
not Mrs. Smith whom I have nursed for years and whom I like very much. This is
only a demented patient. She does not understand and feel." At worst the nurse
treats the patient like a thing.
Another consequence may be demands for orders by use of pathological games.
The real goal is to get rid of the guilt. "Tell me what I have to do, so I can blame
you!"
How can the double bind be resolved? You can help the care workers to escape.
Some care workers in long-tern care should not be there. We need mature care
workers in the care of old demented patients. You can facilitate meta-communica-
tion among care workers, e. g., arrange group discussions. By discussing, the care
workers can verbalize the conflicting demands. The main point is that the conflict
must be solved. There are two main groups of problems here:
1. The level offacts
2. At the level of values.
Does the patient who dies from lack of water suffer from thirst?
In that case how can his suffering best be mitigated: by enema, by intravenous
or subcutaneous infusions, by intensive mouth care, by morphine given when nec-
essary?
What is more valuable: a shorter life with minimum suffering or a longer life
with more suffering?
Who should make the choice for the patient?
In one of our research projects we have asked the question: Can some problems
be solved by using bottle-feeding of the old, demented patient in the terminal
phase?
Our argument goes like this:
- The nipple does not hurt the patient as much as a spoon or an infusion or tube.
- You cannot force the patient to eat by using a nipple. If the hole is of the right
size the patient has to suck in order to get food.
- The patient swallows best when sucking.
Then the patient can eat until he loses his sucking and swallowing reflexes Then he
dies. But he dies because he cannot eat any longer not due to a decision by the care
workers.
Feeding Problems 199
Here we have not only a problem of facts but also a problem of values. Some
nurses in Sweden feel it is wrong to treat an old patient like a baby. It is unnatural
and disgusting.
The task for the nurses in this feeding situation is a paradoxical one.
She has to simultaneously accept the childlike behavior of the patient (fetal and
neonatal reflexes reappear) and remember that the patient is old. He has life experi-
ences.
In addition, the nurse has to accept that the patient is dying and at the same time
is living. He even has the right to have sexual experiences. Some patients show plea-
sure when sucking. It can be interpreted as oral sexuality. This conflict between life
(sexuality) and death is the main human conflict. The feeding of these old, dement-
ed patients is not only a matter of food but also a matter of love.
IV. Nursing: Cultural
and Religious Aspects
Introduction
Since attitudes toward health and disease are socioculturally determined, nursing
care must take into account the beliefs and practice system of the individual. This
includes ritual as well as political and social issues. The patient must be viewed in
his specific cultural context. In addition, since the individual does not live in a vacu-
um, this cultural specificity must also be taken into account with the cultural diver-
sity of the society as well as the personality and culture of the nurse.
Religion also plays an important role - both by its presence (implicit and explic-
it) in the individual and by its absence. Visiting the sick and ministering to the sick
is viewed by some religions as a religious virtue and duty. In the Jewish view,this is
considered part and parcel of medical ethics, by its encouragement. Care societies
work as a group and individually in order to provide for the religious and material
needs of the patient.
The nurse, in addition to her professional duties, also serves as a parent-surro-
gate. This may mean treating the physical~ emotional, and spiritual needs of the pat-
ient. The professional dedication of the nurse to her duty has been compared by
some to the religious devotion of the believing.
Christian philosophy, in its transcendent as well as its radical sense, also stresses
the ethical aspect of care and treatment. Norms and values (parallel to principles
and action, in some professional circles) are essential to nursing treatment philoso-
phy. One cannot over- or underemphasize the ethical aspect.
This section contains papers from Israel, Italy, and South Africa that explore the
areas of culture and religion as they relate to nursing care.
The Economics of Caring
K. M. Boyd
Although I am not an economist, I would like to try to explain why I think that
economics is too important a subject to be left to economists. Economics is not just
a science but also the practical art of political and household economy, which in-
volves making moral judgments. Nurses, I suggest, are and should be practitioners
of this art. It ought also to be possible for nurses to discuss these judgments ratio-
nally, in an open forum, and sympathetically with those affected by them. The eco-
nomics of caring, sounds like a contradiction in terms but actually is not, because
genuine caring implies wanting to see the cared-for good realized and because we
commonly care for the good of more than one person or object. Dispensing with the
preliminaries let me turn straight away to some of the moral questions raised for
nursing by the economics of caring. Let me do this by talking first about problems
which arise at what economists call the ,macroeconomic level, those which used to
be called questions of political economy, and second about problems at the micro-
economic level, those of what used to b~ called household economy.
At the macroeconomic level, or in terms with which political economy is con-
cerned, a major feature of the economics of health care has been the steep rise in ex-
penditure on health services in developed countries since the 1950s. A typical West-
ern country which "had spent 2Y2 per cent of its national product on health in 1950,
was spending 6 per cent of a much larger GNP in 1969" [2, p 18]. In Britain (which
has spent proportionately less on health services than the average for Western coun-
tries), total expenditure on the National Health Service (NHS) between 1949 and
1979 "more than doubled and the volume of resources devoted to the NHS ... in-
creased in every year except 1952." Total NHS expenditure, moreover, grew "faster
than the rest of the economy in almost every year since 1954, rising from 3.4% of the
gross domestic product (GOP) in 1954 to 5.6% in 1977 [3, p 332].
These rising costs, In Britain at least, reflected public and professional optimism
that equal access for all to modern medical treatment and prevention would im-
prove general levels of health and possibly in time even reduce the need for health
services. In terms of many previously fatal or disabling conditions, this optimism
seems in part to have been justified. But the multifactoral etiology of many remain-
ing health problems and the growing health needs of an increasingly elderly popu-
lation have raised doubts about the returns which can be expected from continuing
to spend an increasing proportion of natural resources on conventional health ser-
vices and, in particular, on acute hospital medicine. At the same time, the potential
benefits of increased expenditure on care of the elderly, the mentally ill, the mental-
ly and physically handicapped, and on preventive medicine and health education
have been difficult to demonstrate in the dramatic "live-saving" terms which mobi-
lize public opinion and the political will to spend. A further feature which has
blunted earlier optimism, of course, is a growing realization of the role of demand
as well as need in the health care equation. Even with continued optimism about the
benefits of increased investment in medical excellence, however, growth on the
206 K. M. Boyd
scale experienced since the 1950s could not have continued without, on the one
hand, further growth in the national economy and, on the other, some willingness to
sacrifice other purposes to which public (or, for that matter, private) expenditure
might have been applied. In fact, the absence of significant economic growth, in
Britain at least, has now led to political decisions which have slowed down the rate
of growth in health service expenditure. This development has made even more
acute the problem of the proportion of the national wealth which should be spent
on health services, as opposed to other social purposes. It has also made more diffi-
cult problems about the proportions which should be spent, within the health allo-
cation, on different categories of need or demand, that is, on different patient
groups or different specialties or services, on the hospital as opposed to the commu-
nity, on different geographical areas with histories of unequal provision, or on the
particular needs of different socioeconomic classes, including the most deprived.
The problems of proportional expenditure, both between health services and
other public services and between different categories of need or demand within the
health service allocation, have a significant feature in common. It is difficult, and
maybe impossible, not only to quantify these needs and demands entirely satisfac-
torily for predictive purposes but also to isolate any single need or demand from its
interaction with the others. In Britrun, for example, there is a growing impression
that unemployment may be adding to the burden of national ill health [4] and mor-
tality [5]. Although evidence for this is as yet difficult to establish scientifically, it
raises the question of whether money would not be better spent on attempts to
create new employment than on health services for the casualties of unemployment.
Within the health allocation, too, the difficulty of quantifying and isolating the
needs and demands of different categories can be seen. A political decision to
spend more on, for example, the handicapped, at the expense of acute hospital and
maternity services might lead to poorer early detection and prevention of handicap
and thus to an even greater proportion of handicapped people requiring care. Or
again, current emphasis on prevention and health education, if successful, could
create not only the benefits of longevity for individuals but also, eventually, much
heavier demands on geriatric services.
Questions of this kind raise formidable problems for all who are concerned to
see an equitable distribution of resources among different classes of patients and of
the population and among the different interest groups within health services them-
selves. At present, despite many attempts by economists, no satisfactory scientific
method of setting priorities exists. A recent Scottish Government Working Party on
Priorities, in reaching this conclusion after an exhaustive study of possible methods,
commented that "a pragmatic approach, in which value judgements would neces-
sarily playa particularly large role, was best in present circumstances" [6]. This con-
clusion, in emphasizing value judgments, underlines the importance of moral judg-
ment in the macroeconomics or political economy of caring. The pragmatic
approach this Scottish Working Party adopted (in giving priority to those suffering
from multiple deprivation as well as to groups selected for demographic or epide-
miological reasons) expressed a collll11itment to the particular moral value of great-
er equity. As it admitted, however, its approach was a pragmatic one, and in the ab-
sence of overt public consensus about the values or principles on which allocation
should be based, the question of whose value judgments were to count, and for how
The Economics of Caring 207
much, thus became particularly important. In the macroeconomics or political

economy of caring generally, indeed, the problem of quantifying and isolating the
needs and demands of different groups, and the inherent difficulty of relating these
needs and demands to moral values, let alone the problem of establishing priority
among moral values, makes the question of rules of procedure of the greatest signif-
icance. In parliamentary democracies, there is a strong presumption that the only
ultimately satisfactory procedural rules are those of political government. This view
is not shared by those systems of government which, in principle at least, value
equality above liberty. Nor is it obvious even in parliamentary democracies how to
strike a fair balance in matters of health care priorities between the rule of politics
and the role of professional advice. Quite possibly, of course, there are no entirely
satisfactory procedural rules. Calabresi and Bobbitt, for example, have carefully an-
alyzed the full range of resource allocation methods - the market, politics, lotteries,
and a customary or evolutionary approach - together with many refinements of
these methods. Having done this, they conclude that all methods of allocating
scarce resources support some moral principles or values only at the cost of violat-
ing others and that the cost of an open society is the painful tension this knowledge
brings. Thus an open society, if it is also to be a moral society, they argue, "must de-
pend on moral conflict as the basis for determining morality" [7].
This moral conflict at the heart of the macroeconomics or political economy of
caring is clearly of importance to nursing ethics, not least because wage and salary
costs normally represent the largest item of health service expenditure and because
in most developed countries nurses are the largest single group of health care per-
sonnel. In Britain, for example, wage and salary costs amounted to about 70% of
NHS expenditure [2, p 19]. The total NHS work force is now over 1 million, out of a
total UK population of 55 million [3, p 177]. It has been estimated that if manpower
trends during the 1960s had continued, half the population would have been em-
ployed in hospitals in the early 21st century [8]. In 1975 the typical Western propor-
tions of health service personnel groups were 15 doctors, 27 nurses, 4 dentists,
5 pharmacists, and about 100 supporting stafffor every 10000 population [2, p 19].
In 1977, nursing and midwifery staff represented 43% of British National Health
Service employees. The next largest group was ancillary staff and others at 21.9%,
followed by administrative and clerical staff at 12.3%, doctors at 6.7%, and profes-
sional and technical staff at 6.5% [3, P 178]. As members of this large professional
group, as in many cases health care planners and managers, and as citizens, nurses
are confronted with these macroeconomic moral conflicts. In coming to terms with
this, nurses may well also come to agree with Calabresi and Bobbitt that, while trag-
ic choices inavoidably "need to be made," are not the easier for the understanding
of them [7]. A no less difficult conclusion may well be reached in relation to the mi-
croeconomics of caring, that area which is closer to household than political econ-
omy. Nurses are involved in this area also as professionals, as planners or managers,
and as citizens. However, the moral issues involved here can perhaps be better illus-
trated by seeing nurses, on the one hand, as major users of resources in day-to-day
health care and, on the other, as advocates of the rights and interests of individual
patients. A great variety of examples could be given of the moral problems which
arise for nurses in the microeconomics of caring either in the ward or in the commu-
nity, but let us just discuss one apparently trivial incident.
208 K. M. Boyd
A nurse is in charge of an acute surgical ward, at one end of which sits an old
lady recovering from skin-graft surgery after burning her leg in front of her fire. The
surgeon has said that she can now either return home or go to the convalescent hos-
pital. He has also reminded the nurse in charge that tomorrow is the ward's waiting
day and he will need the bed. The old lady herself has expressed a strong desire to
go home. But the convalescent home is full, the overstretched ambulance service is
fully committed at another hospital, and the part-time social worker (also unobtain-
able today) has left a message to say that the old lady's only relative (a daughter liv-
ing at a distance) cannot get to her mother's isolated cottage to look after her for an-
other week. Home help is not available because of government economies, and the
district nurse is off sick with inadequate cover. The nurse in charge of the ward is
not convinced that the old lady will be able to look after herself on her own. While
ambulant, she is still very slow, and during her stay in hospital she has seemed at
times confused. Yet on discussing her discharge with her, the old lady is adamant
that she wants to go home: She has electricity at home and tins of food in her larder.
This notwithstanding, she is actually very poor and has not enough money with her
even to pay the bus fare to the road-end near her home, which is some considerable
distance from the hospital. The nurse in charge has considered the possibility of or-
dering a taxi to take the old lady home at the health service's expense and has re-
membered the recent hospital ciryular warning against the use of taxis except in
cases of dire emergency.
In this example of the microeconomics of caring, the nurse in charge has to
count a variety of costs. First, as a major user of resources (as well as a manager and
a professional) she has to count the cost, on the one hand, of using the excellent fa-
cilities of an acute surgical ward for what are convalescent or even social purposes
and, on the other, of using expensive transport at the public expense. The cost in-
volved here is not just to some impersonal public purse. An important aspect of the
microeconomics of caring, particularly at a time of no growth in provision, is the
fact that resources spent at one place are eventually not available at another. At the
end of the line, in other words, are other patients whose needs, whose health, and
even, in some cases, whose life may be threatened by the nurses's action. As a user
of resources, it is easier perhaps for the nurse to see this in terms of the last-minute
emergency patient who may not get a bed in her ward tomorrow. But sufficient taxi
fares may well add up to a decision, next year, to postpone the replacement of some
important piece of equipment in her ward or elsewhere.
The nurse, however, is also the patient's advocate, and she also has the problem
of counting the cost of what is best for the old lady. Part ofthis problem can be seen
as a question of what is in the old lady's interests, and the nurse, as we have seen,
has serious doubts about sending her home to a situation in which she may not be
able to look after herself or may injure herself again. These considerations, more-
over, may well be mixed with counting the cost to the hospital or the profession
should any such injury or death become public knowledge. But the question of
what is best for the old lady, of what is for her good, is not simply a matter of calcu-
lations about what the nurse sees as her interests. As an advocate of her patient, as
someone who cares for her good, the nurse must also consider the patient's rights.
Generally speaking, rights include positive rights (rights to have something done for
one) and negative rights (the right not to have what one does not want done to one).
The Economics of Caring 209
Generally again, positive rights (beyond a basic, albeit variable, minimum) are
rights which can only be delivered if the resources to do this are available, and be-
cause of this, positive rights are not always easy to defend. In the old lady's case, for
example, it would be difficult to justify that she had a right to the taxi fare. On the
other hand, negative rights, including the right not to be interfered with in the exer-
cise of one's personal freedom when this does not harm other people, cannot easily
be denied without serious moral cost. In the old lady's case, therefore, the nurse,
whose knowledge of the hospital's ways puts her in a stronger position than the old
lady, may be morally at fault if she deceives the old lady by saying that there is cate-
gorically no way in which she can go home. What I said earlier about the need for
practical economists to discuss the reasons for moral judgments rationally in an
open forum, and sympathetically with those affected by them, is clearly relevant
here.
In the microeconomics of caring, then, the nurse's different roles raise a variety
of conflicting moral considerations. When we discuss cases of this kind in our ethics
seminars, students commonly suggest a great variety of pragmatic "ways round" the
moral dilemmas involved, often at the expense of discussing the fundamental moral
issues. The ingenuity they show in doing so is something to be grateful for, since in
practice it will often be needed. But in practice, too, there are also times in the mi-
croeconomics of caring when ingenuity - ,either at that time or at the end of the line
- is not enough and when tragic choices, which offend against some moral value
which is important to us, have to be made. In these circumstances, the household
economy of caring demands acutely, of fallible individuals, what the political econ-
omy of caring demands acutely, of fallible individuals, what the political economy
of caring demands more chronically of societies, namely, the moral courage to act
decisively in the face of irreducible tensions and unrecoverable tragedy and also,
one might add, the moral courage to live with such decisions.
References
1. Nightingale F (1969) Notes on nursing (1860). Dover, New York

2. Maxwell R (1975) Health care: the growing dilemma. McKinsey, New York
3. Royal Commission on the National Health Service (1979) Report, Crnnd 7615. HMSO, London
4. Boyd KM (ed) (1982) Work, health and high unemployment: papers from a June 1982 Edinbprgh
medical group consultation. Contact Interdisc J Pastoral Stud 76: 3
5. Timmins R (1982) Unemployed have higher death rate, study shows The Times, June 6th, p 2
6. Scottish Home and Health Department (1980) Scottish health authorities priorities for the
eighties. HMSO, Edinburgh, p 67
7. Calabresi G, Bobbitt P (1978) Tragic choices. Norton, New York
8. Cooper MH (1975) Rationing health care. Croom Helm, London, p 36
Culture
Illness: A Time of Stress Involving the Relationship

Between the Individual Personality and Cultural Backround
M. B. Agostino and J. Sansoni
This topic may be considered under several, apparently unrelated, aspects. Nursing
is not and should not simply be care of the patient without regard to the person. The
concerned relationship between the individual and his/her illness is important for
the nurse both with respect to the actual illness (a problem which is obviously the
same for doctors and nurses alike, according to their particular responsibilities; this
becomes an individual, ethical problem) and the condition of the patient in relation
to the treatment he receives. In Qther words, if it is true that no illness can be com-
pletely foreign to a patient's culture (in its anthropological sense, which will subse-
quently be discussed), it is also evident that the "period" of illness is characterized
by a conflict which is culturally determined. The problem of the relationship be-
tween personality and culture, much discussed by anthropologists, is still one of the
most delicate theoretical topics, both scientifically and practically. It is not possible
here to explain the theory of personality and culture relationship, but it must be not-
ed that independent of different opinions among anthropologists, this relationship
is very strong. However, at this point we might briefly explain what we mean by
"culture." The relationship does not signify "complete conditioning," as for exam-
ple, the theory of "the basic personality" would intend. Relationship means a "dy-
namic" tension, in conflict as in function, task, and service. By culture we mean the
total environment which the individual learns, naturally and unconsciously, to be-
come a person, by way of language, eating habits, customs, norms, values, in history
of the group to which he belongs. Consequently, in moments of great stress, the in-
dividual naturally tends to hold on to familiar habits which are natural to him (natu-
ral obviously means "cultural," as the nature of homo sapiens is his culture) and to
values which will help him gain strength and security and defend her his identity.
It is therefore evident that illness itself, and all that it involves in hospital, creates
confusion in daily life and exposes the personality of the patient to risks. The lone-
lier the patient (illness cannot be shared with anyone), the more is demanded of on
whom his well-being and recovery depend.
This is only a short introduction to the problem we intend to discuss - the pat-
ient's cultural condition. Cultural condition means, above all, to "live" at a specific
time in a specific place it varies from culture to culture and shapes the environment
in which daily activities take place.
In our Western culture, we are all used to observing certain timetables, which
not only regulate daily life but also vacations, religious holidays, and so on. The
worry about time, which for us is so deeply rooted, is not so relevant in other soci-
eties. Consequently, the timetable in a hospital, with regard to cleaning, sleeping,
Illness: A Time of Stress Involving the Relationship 211
eating, working, etc., may be very different to what some patients are used to. For
example, time of meals and quantity offood, time and names of cleaning both indi-
viduals and the hospital environment, visiting time (which precisely shows the "di-
versity" of the patient's environment) - in Italy people never visit one another in the
early afternoon, which is almost always the visiting time in hospitals. Hospitals are
not run in accordance with the outside environment, but according to their own
needs. These remarks can also apply to space: territoriality with respect to the feel-
ing of one's own body, one's own physical existence and ego, the concrete and psy-
chological space between one individual and another, one's own uniqueness. These
needs, which are universal, vary among human beings, according to culture. Thus
some individuals have a different "measure" of necessary space, of the distance be-
tween themselves and others, depending on their cultural habits.
This distance is so "instinctive" that even though no one has ever measured it in
meters or centimeters, we all generally assume the "right" distance when talking to
someone and we will immediately notice if someone is standing too near or too far
away from us while talking. If one steps too close without knowing the person, this
is interpreted as a signal of "bad manners" or a "sexual" message, according to
what is considered the right distance. Some anthropologists consider that the dis-
tance is dictated by the security needs of one's own territoriality, which is the same
as in animals. It is not possible in this Pflper to make an analysis of the concept of
territoriality; it is, however, important to realize that the need exists and that it dif-
fers from one culture to another. Translated into real terms, this means that the pat-
ient needs his own "personal space," sufficient not only for his basic needs but also
for those unexpressed "limits" that are internalized and dependent on his cultural
habits.
The desire not to be allocated a central bed should be satisfied both if there are
free beds in the ward and when distributing hospital space. Obviously, these obser-
vations concern all the personal articles of the patient, clothing, furnishings, color of
the walls and wards: It is difficult to imagine a complete change, but these should
nonetheless be considered. The hospital, as generally organized, is one of the "total
institutions" (as defined by the anthropologist Goffman, referring to barracks, pris-
ons, monasteries, and psychiatric hospitals) which in its organization is detached
from life outside; it functions only for itself and consequently everything is homog-
enous - patients, beds, walls - equal objects, alike in color and shape.
This is one of the reasons why patients live the period in hospitals and clinics as
a particular time of "regression" to childhood, a time, in fact, of life that society tries
to homogenize (children live, more than anyone else, in similar conditions with re-
gard to their "body", while society indicates how to bring up children, when they
should eat and sleep, what "articles," from toys to pots, are not suitable unless they
are the same as the others). This form of childlike regression, encouraged by society,
urges the patient to give up, to leave himself in the hands of those nursing or assist-
ing him (probably depending on sex, as women are, in fact, much more used to tak-
ing care of themselves than are men). This is a form, of "abnormal" behavior, which
leads to an aggressive mood that is more pronounced toward nurses than to doctors.
This is an important point: The nurse's image, both because she is, to the pat-
ient, in a subordinate position compared with the doctor, and because she is the one
who actually "manipulates" the body of the patient, thus becomes rather ambig-
212 M. B. Agostino and J. Sansoni
uous and interpreted both as a ''vice-mother'' (with all that this connotes) for
adults in a weak position, and as not completely reliable in terms of technical
competence as regards care. In other words, a "mother" is not a "doctor," although
she was considered so during childhood. This results in a trust-mistrust which, ac-
cording to a patient's illness and psychological behavior, will lead him sometimes to
ask too much of the nurse on an emotional level and too little on a technical level.
The nurse's task becomes, in this way, quite difficult because in a society where the
doctor tends to become a purely technical figure, the technical specialization is
overestimated and this means that he attains a charismatic and untouchable image.
The nurse is paying the consequences; in fact, the more "emotional" assistance is
required from her, the less her technical competence is considered.
It is in this perspective that we mentioned the real manipulation of the body of
the patient as one of the "neuralgic" points in the complex relationship; patient-
nurse-doctor-illness-culture. This relationship, in fact, "passes" through the body
and the way the body is interpreted in very single culture. The soul-body or spirit-
body dualism is difficult to extinguish, even though we try to today. It has character-
ized our history, meant that "serving the body" of others is not mortifying at all, at
least in it's most severe aspects, either for the sick person or for the nurse. This is be-
cause only the body is nursed and not the "total person" or ego of the sick person.
On the other hand, until quite re~ently, nursing was a voluntary choice, almost al-
ways performed as a service to God through the sick (e.g., nearly all religious con-
gregations, especially female, started with this objective). Today, on the other hand,
all treatment of the body is interpreted in a much more humiliating way both for
those performing and those receiving the treatment. The body is considered the
"whole person," totally part of one's ego, and therefore everything it involves con-
cerns the person in his uniqueness, absoluteness, and totality.
The concepts of "decency" and "shame" exist, although the contrary has just
been in ferred; what has probably changed is the meaning and motivation of decen-
cy. It has lost its typical Catholic characteristics, concerning the sinfulness of the
body and has become "self-defense" in relation to others. Serving the body of oth-
ers, therefore, has become one of the "lowest" tasks because it means to serve an-
other person totally. Even though it is not possible to describe completely in a few
words this transformation, one can, we suppose, without hesitation establish that
the "professionalization" of almost all tasks serving basic needs of the body de-
pends on this transformation of the meaning of "serving." The shortage of nurses is
correlated, not infrequently with a shortage of all those who serve the body, includ-
ing maids, servants, cooks, cleaners, and even housewives.
One tries with professionalism (which in this case does not correlate with techni-
cal competency and is very important) to "impersonalize" the service, to make it as
"neutral and distant" as possible, both for those serving and those receiving (clean-
ing companies for example, where personal contact no longer exists). Therefore the
nurse's difficulty in relation to the patient's way of interpreting the significance of
the body is in transformation, more or less in all cultures but especially in the West-
ern world. The manipulation of the body to meet its basic requirements is commit-
ted to the nurse and this produces several reactions that are almost impossible to
control. Due to the complexity of the question, we will just consider one of the most
important aspects: the difference between the sexes in perceiving one's own body -
and the particular illness that has stricken it due to the relationship between person-
ality and culture; this involves the admission of males into the nursing profession.
This is a important part of the dramatic relationship that patients live with cultural
norms, with their identification as a person, with that transformation of the relation-
ship with the body that one would always like to respect, even in the most difficult
situations, but rarely succeeds in doing so.
The mortification with which one perceives the necessity of letting others assist
one's own body is even more serious and quite difficult to solve in a short time (ex-
cept if you accept, as it seems to me, the authoritarian organization of hospitals as a
model). Regard, for example, male nurses in wards with only women, especially in
gynecology. The violence that women have to accept as patients would not only not
be accepted when living a normal, healthy life (such as nudity, touching, etc.) but
would even be considered badly by society, is totally part of the personality-culture
relationship previously mentioned. How can we expect a patient who is already in a
weak position to submit herself to something that would not even be considered in
daily life? Therefore a double violence exists due to the double contradiction with
respect to cultural and social values.
If it is so necessary for men to start to,deal with basic needs, they can and should
do it, at least for now, in male wards, even relieving female nurses from the task that
they have always done: nursing men. TJ;tis would probably be viewed in a positive
way by male patients, who have until now often regressed to childish behavior just
because of the presence of female nursing personnel that they identified as a mater-
nal figure.
Besides this one cannot remove (not by having male nurses nor even mentally,
as this would be hypocritical and impossible) the implied sexual relationship be-
tween men and women; neutrality, on the other hand, would lead to the opposite of
what is meant by considering the patient and his body as an object.
But this can't take place because sexuality has its origin in communicating mes-
sages through the body and besides men are still (and will be for a long time, in my
opinion) in the habit of considering the woman's body in a very basic and rough
manner.
It might be superfluous to observe that gynecologists and doctors are generally
men! This is a historical reality and not a reality of values. Only men could study,
only men could have a social position, only men had the power. That doctors and
gynecologists are men is not only a commonplace reality, when trying to indicate
values for the future, but it is also the result of women's historical and psychological
condition, that in almost all cultures, including the Western world, has until now
been "taboo" especially in moments of reproductive activity (menstruation, preg-
nancy, delivery, and puerperium) which made them unfit for social activities.
Of course one can't draw every possible conclusion in this occasion as there
would be several topics to discuss, many of which are interesting ideas for further
research and have often, up to now, been left unsolved.
I would like though to mention at least some of them, which might be useful to
us. For example, I think that it is very important to consider the different ways in
which some illnesses are interpreted by society, and the different ways that patients
experience their illnesses. It is sufficient to mention, for example, the various ways
in which psychiatric symptoms are considered by different cultures: schizophrenia,
214 M. B. Agostino and J. Sansoni
psychosis, hallucinations, all of which are doubtlessly thought of as various kinds of

mental illness by us, in other cultures may be considered as symptoms of a religious
vocation. For example the witch doctor must assume a feminine appearance to be
able to experience his visions and communicate with the transcendent. Obviously
passive homosexuality acts as a substitute for femininity, so much so that the witch
doctor will dress in female clothes and become the wife of the head of the group.
These are cases which would doubtlessly be diagnosed as pathologic, with perhaps
the exception of homosexuality, by the Western culture.
Another case of illness experienced in a negative form by society is that of ep-
ilepsy which, in Italy for example, has been until now regarded as "shameful," espe-
cially for the female sex, so much that it was kept hidden even from the doctor in
certain parts of Italy, because such women had difficulty in fmding a husband.
It is necessary to at least mention the problem of pain and the different ways in
which it is experienced and considered from one culture to another. This is of
course too complex to be dealt with in a paper which is already too long. However,
the way one suffers is strongly influenced by one's own culture (for example, the
way in which the "value" of physical suffering has been inculcated by Catholicism
in order to "ascend").
Suffering is also shown differently according to sex, in as much as the male, in
the "strong" role which is forced upon him by society, must control his suffering
even when he is in great pain, whilst women on the other hand, can show their pain
more openly.
However, where birth is concerned, women must also show themselves to be
strong in the maternal role that they are expected to accept lovingly, and they are of-
ten chastised, even by the medical staff, if they complain in a way that then consider
excessive. All this serves to show, once again, how cultural and social conditions
can influence the patient's behavior, and it gives rise to another problem: whether
or not the external behavior demanded by society can actually cause pain (with-
in certain limits), more or less intensely according to the external manifesta-
tions.
Lastly I want to mention the anguish, the anxiety, and the fear experienced by
dying patients or those with very severe conditions.
Death is experienced differently according to cultural convictions, one of which
being religion. But even religious convictions playa different role than usual, this
being the moment when they should be of real help, when they can be shown as be-
ing weak or doubtful. This is almost always the case, whatever the religious convic-
tions ofthe patient may be.
Death is "seen" differently by someone on the brink of death and therefore the
state of almost complete isolation and solitude in which he fmds himself may per-
haps be aggravated by an environment or atmosphere which is profoundly "believ-
ing" in life after death. This happens because the person cannot fully express his
fear, anguish, and uncertainty about the "life beyond" to those who surround him
because, to console they speak to him in terms of "faith." On the other hand, this
same solitude is felt equally by those who do not believe in an afterlife and whose
fears are consoled with false hopes of cure. It is clear that a patient in grave condi-
tion is nearly always aware of the state he is in, even if he passes constantly from
hope to fear; something which is not perhaps completely verifiable because a mori-
bund person is one who "lives" his death alone and is unable or incapable of ex-
pressing it.
I believe that this "separateness" of the moribund person, which is often seen as
something positive by other cultures, who may leave him alone or even kill him be-
fore death arrives "naturally," so that it seems to them that he isn't really dead.
Lastly it's sufficient to think of the avoidance of the moribund person and later
of his corpse, which is considered as "contaminating" by almost all cultures. This
means that, whilst protecting the living, in reality the patient is left extremely isolat-
ed at the time of his death. Summarizing, death cannot be "experienced" and there-
fore cannot be communicated.
Finally, faced with such a vast range of problems arising from the complex rela-
tionships among doctor-nurse-patient-hospital-culture, the program of education
for the nursing profession cannot but include a thorough knowledge of cultural
aspects. Furthermore, for each single topic, the nurse must ask herself if what she is
doing fulfills all the needs of the persona of the patient, as a member of a particular
culture with it's own values, meanings, habits, etc.
What we have tried to emphasize in our I paper is that nurses in their profession-
al role should, first of all, be aware of the basic physical and psychological needs of
patients. Wherever nurses may work or whatever their career may result in, it's es-
sential to our profession to care for the patient's body in all it's physical expressions
as well as in it's personal significance.
Religion
Nursing in Jewish Medical Ethics: Visiting the Sick

S.Kottek
1 Introduction
To nurse (from the Latin) means etymologically to nurture, to nourish. Therefore, a

nurse was first of all a woman who suckled and, secondarily, one who took care of
an infant not her own. It appears thus that the woman who cares for or cures the
sick was originally meant as one who nourishes. In the same manner, the hospital
was first a hospice (from the Latin hospitium), a shelter, or hostel, i. e., an inn for
strangers [2, 3]. Modern Hebrew has adopted the noun aboth (sister) with the Chris-
tian background of religious orders devoted to the poor and the sick. The more ac-
curate term metapeleth has been,derived to designate dry nurses or domestic ser-
vants.
This philological introduction shows us that there are apparently no older roots
to the nursing profession in Jewish antiquity and the Middle Ages. We may then ask
ourselves what happened to the poor sick people, especially those who had no fami-
ly to care for them. As a matter of fact, the religious duty of visiting the sick (bikkur
holim) was quite efficient in replacing the absent nurses. Close or remote relatives,
friends, neighbors, in fact, anyone who happened to hear of an ill stranger in town,
assumed the office of a nurse and nobody was left in want.
We have dealt elsewhere [2] with the similar reasons why Jewish hospitals only
appeared towards the end of the eighteenth century, although there were plain shel-
ters for the strangers and the sick throughout the Middle Ages and perhaps even in
Talmudic times. Strong family ties, strict rules for hospitality, and charities were the
main reasons for the absence of public health care. Interestingly enough, modern
trends have stressed the noxious effects of hospitalization and developed the sys-
tems of home care and of ambulatory treatment, thus leaving the patient as much as
possible in his own environment. Once again, we are in the presence of an old-new
idea! Let us now delineate a brief outlook on legalistic and ethical rules related to
the visiting of the sick.
2 The Duty of Visiting the Sick
To bring home guests and to visit the sick are two religious duties that have no lim-
its: the more, the better! (Babyi. Talmud Shabbat, 127 a). It is of course not by mere
chance that those two religious duties are cited together (in a list of ten foremost
rules). They may be considered as complementary, because together with the obli-
gation to give money for the needy, they solve the problem of public health care.
Nursing in Jewish Medical Ethics: Visiting the Sick 217
The Lord Himself showed the way to the patriarch Abraham when He sent him
three angels to visit him after he had circumcised himself (Genesis 18: 1), a lesson
that should not be overlooked (Babyl. Talmud Sota, 14a).
In Talmudic times, renowned rabbis used to fulfill this religious duty. Rabbi
Aqiba (second century) paid a visit to one of his disciples during his illness and had
his room thoroughly cleaned and thus the patient recovered. The young scholar ex-
claimed: Rabbi, you revived me! Rabbi Aqiba accordingly taught: he who refrains
from visiting the sick is close to committing bloodshed! (Babyl. Talmud Nedarim,
40 a).
But it is not always easy or rewarding to approach a sick person. Let us cite the
case of Rabbi Simeon b. Yobai who once visited a man who was lying with an intes-
tinal disease and was reviling the Lord. Rabbi Simeon exlaimed : You worthless
man, why do you blaspheme, when you should be asking for mercy! The man
answered: I pray the Lord should take my disease off and lay it upon you! The Rab-
bi answered: This is exactly what I deserve for having neglected the study of the law
in order to occupy myself with vanities. (Aboth de Rabbi Nathan, 41, 1). This
strange story deserves a commentary. Mpst commentators think that the duty of vis-
iting the sick should not be preferred to study of the law if it may be done by others.
To me it seems that this story exemplifies the necessity to address an ailing person
with mild words, not harshly, or else visiting the sick turns out to be a vain enter-
prise. This is beautifully expressed in Psalm 41, verse 7: "Ifhe [the enemy] comes to
see [me, lying ill], he speaks vanities, his heart gathers falsehood he goes out and
tells it abroad." The enemy here can be seen as he who comes with inimical feel-
ings; he may bring no help to the sick.
This duty appeals to the body, the pecuniary resources, and the soul of the visi-
tor. He is requested to care for the physical and financial needs of the sick and pray
for his recovery. It is therefore seen as a total involvement, not a merely formal act.
3 How to Fulfill the Duty
We do not intend to detail all the rules formulated by the sages [1, 5] concerning our
topic, but let us cite some of them. Relatives and close friends may enter at once,
others should wait 3 days before paying a visit to the sick. The more they go, the bet-
ter, provided that they do not disturb him. There are several diseases where visits are
not welcomed, particularly if speaking is difficult for the patient. Visits should not
be paid during the first 3 hours of the day nor during the last 3 hours. Maimonides
(Mishne Tara, Hilbot Evel, 14,5) explains that at these hours the patients were be-
ing cared for and therefore visits were not welcomed. The visitor should, before
leaving the room, pray for the recovery of the patient. The latter should never be left
alone and he should be supplied with food in accordance with his disease.
218 S.Kottek
3.1 Psychological Considerations
Psychological considerations are particularly important. The visitor should not be

seated higher than the patient; he should face him and tell him invigorating and
cheerful tales. The visitor should enter the room with a merry countenance and one
should choose people of cheeiful character to attend the sick. The visitor who sympa-
thizes with the patient takes off V60th of his disease (Babyl. Talmud N edarim, 39 b),
which probably means that he relieves his anxiety. An interesting remark is that if
both the patient and the visitor are of the same age, the visitor takes over this V60th of
the disease on himself. This is evidently meant as a transfer of part of the patient's
anxiety to the visitor. If the visitor feels that he brings no relief to the diseased per-
son, he should take leave. In case of a serious disease, one should stay in the ante-
room, ask if the patient needs any help, listen to his lament, and pray for mercy on
him. We would like to stress the need of listening to his complaints, already requested
by Nachmanides (thirteen century) [5].
3.2 Organized Sick Care
As a general rule a man may attend a sick woman and a woman a sick man. But in
case of an intestinal disease (for instance dysentery), a man can attend another man,
but not a woman. But a woman may attend a man even in this case.
Regarding epidemic diseases, there is no duty to visit such dangerous patients
and put oneself in real danger. In such cases there are paid volunteers who will be in
charge of the care of the sick. However, there were different opinions, some of the
sages would make no difference between epidemics and usual diseases.
The general duty of giving money for the poor includes providing for the sick.
There have been organized societies in Jewish communities since very remote times,
even in the Talmudic period and throughout the Middle Ages [4]. Sometimes the so-
called bevra kadisha cared for the sick and the dead as well. In other cases there
were special societies for bikkur bolim (visiting the sick). In the medieval hekdesh
(shelter) usually attached to the synagogue, the occasional sick strangers were at-
tended by the beadle or his wife (if speaking of women) [4]. But these were mostly
emergency cases: we have already stressed the fact that until the end of the eighteen
century sick people were usually attended to in private homes.
4 Conclusion
The care of the sick may be considered as part of the duty to care for the poor, the
orphan and widow, and the stranger. Sick care is first of all hospitality, and if you
cannot take the diseased into your own house, then you are requested to go to his
house and help him in any possible way.
The modem Hebrew word for nursing is Stud, a root that appears no fewer than
six times in the Psalms. Again, the meaning ofthis word is to support, to strengthen,
to assist, but also to satiate (cf. Genesis 18: 5).
Nursing in Jewish Medical Ethics: Visiting the Sick 219
The best conclusion could be taken from the said Psalms, where, once again, the
poor and the sick are treated together:
Blessed [is] he that considereth the poor ... The Lord will strengthen him upon
the bed oflanguishing: Thou wilt make all his bed in his sickness. [Psalms 41: 1,
3]
The Lord himself will give support and assistance:
Hold Thou me up
And I shall be safe. [Psalms 119: 117]
References
1. Karo J (ed) (1911) Shulhan Arukh, "Yore Dea," & 335, Romm, Vilna
2. Kottek S (1981) The hospital in jewish history, Reviews of Infect. Dis 34: 636-639
3. Leibowitz 10 (1952) History of jewish hospitals (in Hebrew). Dapim Refuiim 11: 3
4. Marcus RR (1947) Communal sick-care in the German ghetto. Hebrew Union College, Cincin-
nati '
5. Nachmanides R (Moses ben Nahman) (1964) Sefer Torath Ha-'Adam, Sha'ar Ha-Mihush (The
book of the knowledge of man the chapter on diseases). In: Chavel HD (ed) The works of Nach-
manides, Vol II. Mossad R. Kook, Jerusalem 'p 16-49
Bibliography
Bernstein H (1974) Yekara de-Hayye (The price of life). Bne-Braq

Halevi D (1971) Yalkut Bikkur Holim (Compendium on visiting the sick). Hamehaber, Tel-Aviv
Jakobovits I (1967) Jewish medical ethics 3rd edn. Bloch, New York p 106-118
Preuss J (1911) Biblisch-Talmudische Medizin. Karger, Berlin p 515-519
Yashar B (1973) Lirefuah Shelema (Back to Full Health). Yashar, Jerusalem
Ministering to the Sick
Y. A. Shapira
1 Introduction
In the Book of Genesis we read about the creation of man, "And so God created
man in His own image - in the image of God created He him." (1: 27)
Man was created by God so that he will represent godliness in this world, and so
man does not belong unto himself alone, but to the one who created him. The status
of man is explained in the Midrash Rabba Chapter 28: "I created all animals and
beasts only for Man and now that he has sinned for what do I need them?" The
world and its content are not of any value except if they fulfill human needs. The
value of man is measured only in terms of quality and not of quantity. Our wise men
have therefore explained in the Talmud (Sanhedrin 37 a) that Adam was created
singly in order "to teach us that anyone who destroys a single soul is looked upon as
if he had destroyed the whole world. And anyone who keeps alive one single soul is
as if he had saved the whole world." Man is a cosmological creature, since each
man's influence is felt throughout the universe.
Considering the status of man in the universe, the Torah commanded us in Deu-
teronomy (4: 9): "Only take heed to thyself and keep thy soul diligently." That
means that man is obligated, and not just allowed, to take care of his soul. The soul
has been given to him only as a loan and he is not the owner of it.
Based on what has been said, Maimonides declared in Hilchot Dayot (Chapter
4, Halacha 1) that it is God's wish that man have a healthy body. If he is sick, he is
not able to perceive the greatness of God's ways. Man must therefore keep himself
distant from those things that may harm his body and behave in such a way that he
stay healthy and strong. Therefore, keeping healthy is a religious obligation, since
man was created in order to understand and publicize God and His ways. Man
must maintain this physical strength and health. Furthermore, Maimonides states in
Hilchot Rotzayach, (Chapter 11, Halacha 4) that "anything which poses a danger to
a human being has to be removed and kept distant and one has to be very careful of
it. This is a positive commandment ofthe Torah. But, if he did not remove the obsta-
cle, but rather puts it down where it creates a danger, then he has violated a com-
mandment." Everything that is done in order to keep the body from danger is, in a
way, a fulfillment of the wishes of God. Conversely, if something is done, even of a
minor nature, to hurt his health, he has sinned against God.
Curing a sickness or arresting its progress by therapy is a holy duty and is con-
sidered as ifhe had saved a whole world. It has, therefore, been accepted as law that
saving a life defers all laws of the Torah. All commandments are deferred when they
endanger the life of a man. His holy value as a human being is greater than the en-
tire Torah. The Holy One is willing to achieve the fulfillment of his tasks and prefers
the existence of man. This has been beautifully expressed by our sages in the Trac-
tate Shabbat (151 b) when they said that for a living being one is entitled to violate
the Shabbat, but for a dead King David one may not.
Ministering to the Sick 221
2 The Sickness
If the life of a person is so valued by the Creator, why do we then have illnesses?
This is mentioned in our Midrashim (Yalkut, Lech Lecha). "Until our forefather Ja-
cob's time, a man used to sneeze three times and then die suddenly. Then Jacob re-
quested that there be sicknesses, so that man will die in his home and depart from
this world quietly, secure in his knowledge that there is a continuation to his life, in
that his spirit will be effective in the world even after his death." Illness is, therefore,
an integral part of life and not just a process of death.
Sickness also was created to warn man that life is not eternal. Whatever man can
do in this world will stay on after he departs. Therefore, the thoughts ofthe patient
are not only occupied with his illness but also concern themselves with his eternal
life. The sickness serves to bring man closer to his Creator and he becomes aware of
his insignificance. He begins to grasp that there is a Leader in this world, who has it
in His power to shorten or to lengthen human life. Suffering cleanses man of his
sins, in order that he may depart from this world with "clean hands and a pure
heart." Therefore, our sages say that a man is not healed of his sickness until his
transgressions have been forgiven. We have been given a vivid illustration in the
Talmud Shabbat (32 a) of the spiritual st~tus of a sick person.
Aman who goes to the market is like a person who has been delivered for judge-
ment. If he has a headache it is like he were standing before a justice and tried for
life. Ifhe climbs into his bed and falls it is as ifhe were pulled up on the guillotine
for sentencing. If someone has been called for sentencing then he is saved if he
has good advocates, but if not, he will be executed. The main defenders are re-
pentance and good deeds.
From this we understand that anyone who has been healed from an illness must val-
ue his life, know how to utilize it, understand what to do with it, and recognize from
whom he has received his life.
3 The Patient and Visiting Sick People
As we have seen above, illness does not serve just to remove a patient from his nor-
mal condition but rather lends meaning to his new status. It has a deep significance:
it comes to purify him and to procure for him happiness when he recovers and re-
gains his evaluation of the meaning of life. The illness strengthens the direct com-
munication between the Creator and the patient. He has suddenly become aware of
his own insignificance. In a minute he has been converted from a strong hero, who
is active and influences his environment, to a creature who depends on everyone's
help. He returns to his childhood years, to the days when he was cared for by others.
This idea, or rather this feeling of dependence, can bring him to a complete break-
down.
This sudden feeling of inadequacy, coming after years of active awareness, can
bring him to a dangerous spiritual downfall, which may worsen his state of health
and hasten his end.
The physical realistic condition of the patient determines the medical treatment
222 Y. A. Shapira
and, yet, it is well known that the will to live and the striving to fight against the sick-
ness influence his medical well-being. Therefore, it is our responsibility to encour-
age the patient to realize that there is a purpose to his life, even under such condi-
tions, and that the illness should not defeat him. He is still the same person, and
there is still hope that he will return to the normal way of life. His need for aid is not
unique as all of us are dependent, to a smaller or larger degree, on our surroundings.
It is written in Genesis (2: 18) "It is not good for man to be alone. I will make for
him a suitable helper."
Since the Torah is a guide for our entire life, it must, and does, give solutions to
the problems of the sick person. It plunges into the depths with the patient, under-
stands how he feels in the innermost parts of his heart, and then guides him in find-
ing solutions to his problems. For example, it is written in the Talmud (Tractate
Nedarim 40 a) that the Holy One Himself feeds the patient. He is not really depen-
dent on others and it not a burden to society, but rather he is elevated to a new sta-
tion and God Himself nourishes him.
Another maxim quoted in the above talmudic portion is that the Divine Pres-
ence hovers over the bed of an ill person. Thus, the patient and his illness serve as a
reason for the presence of God. The broken heart of the patient and his wish to
cleanse himself bring him nearer to his Creator. He suddenly begins to realize that
life is more than the search for happiness and pleasure and seeks to return to a bet-
ter way oflife. But to be exact, the sickness does not bring the person closer to God,
but rather brings his Creator closer to him. He becomes aware that he is not isolated
in his pain or his grief and the Divine Presence is there to give him a feeling of secu-
rity. He prays to God and is certain that is prayers will find a receptive ear. This fact
helps him to overcome his feelings of hopelessness and aloneness.
As a result, the patient reaches a higher status as a man, who communes with his
Creator, and a visit to him is, therefore, of great spiritual importance. We know that
the Almighty visited Abraham after he circumcised himself (Genesis 18: 1), and we
are commanded to act in imitation of Him. That is, visiting the sick is not only a
deed of benevolence, but an act which brings the visitor to a higher level of devout-
ness. The sick, therefore, must be made aware, that he should not consider himself a
burden, but must realize that he is giving his visitors an opportunity fo fulfill an im-
portant commandment, and, at the same time, to be in the Holy Presence. Because
of the importance of this, our sages list visiting the sick as one of the ten things
which we plant in this world and reap rewards for in the world to come. There are
various facets to these visits: first of all he must encourage the patient and try to find
suitable words, which may heal him more than medicines. Therefore, our sages say
that everyone who visits the sick removes Y60 of the illness (Talmud Nedarim 39b).
However, in order to fulfill the commandment in its entirety, it is not enough to visit
him only but one must do something concrete to help him. For example, if one
helps a patient to lie in a clean and orderly room, it gives him a feeling of being less
dependent and he is not ashamed of other visitors. Lying in a clean room and bed
lends dignity to his self-image. It is told in the Talmud that when Rabbi Akiva visit-
ed his sick students he swept their rooms. His students said, "You have revived me."
Where upon Rabbi Akiva published the following maxim, "Everyone who visits the
sick causes him to live and everyone who does not visit him can be likened to a mur-
derer" (Talmud Nedarim 40 a).
Ministering to the Sick 223
Every time one visits with the sick he fulfills a new commandment, on the condi-
tion that he does not cause the patient any inconvenience. He should, therefore,
find the suitable time for his visit in order that it accomplish its purpose. Further-
more, it is the task of the visitor to help the patient to review his past to help him to
repent and to prepare him for departing from this world. Only a person who is an
expert in this can help him to confess his sins and yet to avoid causing him too
much mental anguish. This is done in order to allow him to feel serene and to help
him to face his future.
To sum up, the sick person has a holiness, the Divine Presence is close to him,
and everyone who occupies himself with the patient receives part of this holiness.
4 The Doctor and the Nurse
Since all people are holy creatures, and the Divine Presence is close to the sick, it is
a holy obligation for the doctor and the nurse to take care of the patient in a suitable
manner. This is a privilege, not a professron. The doctor is there to fulfill the task of
the Almighty, who heals the sick and has passed this task on to those privileged to
substitute for Him. It has thus been declared in Yoreh Daya (331 A): "The privilege
has been given to doctors to heal; this is a Mitzvah - a commandment, and he must
save lives. If he withholds this ability to save lives, it is as if he would shed blood."
The doctor may not argue that others of equal ability are available, since it may
have been destined that he is the one to save this person. Furthermore, the patient
may have a special confidence in this doctor and not in another, and this mental at-
titude is part of the process of healing. It is self-evident that because of the demands
of the profession, only these who have the ability and the inclination take upon
themselves this task. Our sages compare a doctor to a judge, since his task is as holy
and elevated as that of a spiritual leader. It is forbidden to live in a city that has no
doctor. There are, therefore, instances of wise experts of the Torah who were also
doctors, such as Maimonides and the Nachmanides, because they recognized in
medicine a holy task. It is interesting to read the prayer for the doctor which is at-
tributed to Maimonides:
You have also chosen me to keep watch over the lives of your creations and over
their health. I am now going to fulfill my assigned task. Help me, oh merciful
God in my holy task and let me succeed, because without your help man cannot
succeed even with the smallest deed. Fill my soul with love for the profession and
for your creatures. Don't allow love of gain, fame or honor to disturb my work,
because these are the enemies of truth. Let me see the patient as a human being,
because that is what he is .... Fill the hearts of the patients with confidence in me
and that they, therefore, will listen to my advice .... Let the world not awaken in
me the thoughts that I have great knowledge but give me strength, time, and the
will to continually improve and to acquire new knowledge. The scope of this pro-
fession is great and the understanding of man is unlimited - it always strives to
improve. In my knowledge of yesterday I will often reveal mistakes today, and
that of today will be found to be mistaken tomorrow. Strengthen me in this great
task so I may succeed.
224 Y. A. Shapira
This prayer expresses the status of the doctor and the weight of his task.
All of this applies even to a greater extent to a nurse. The doctor decrees, but the
nurse has to execute. She has the privilege that without her performance there is
little value to the doctor's advice. She truly fulfills every minute the commandment
of visiting the sick, in its fullest meaning. She helps the ill, washes him, feeds him, so
that without her a patient can nearly not exist. She has to understand how important
her task is and how great is her responsibility. The eyes of the patients are glued up-
on her with hope. But when he senses that she does not hear him, he becomes de-
pressed and gives up. Her responsibility is tremendous, since every little mistake in
the treatment may have terrible consequences. However, she has to have confidence
that if she has indeed the right intentions and follows the correct instructions her
work will surely be pleasing and God will support her.
There is no doubt that if the attitude toward the patient is looked upon as a holy
duty, the treatment will be serious. The devotion and the effort of the doctor and the
nurse toward the patient will be more effective if they remember that the Divine
Presence supervises and helps them.
The Implication of Radical Christian Philosophy
for Nursing Ethics
L.R.Uys
1 Introduction
Ethics is not a special science that can be handled as a separate entity. It is based on
philosophical cosmology (world view) and philosophical anthropology (view of
man). The starting point of the study of ethics or an ethical enquiry should, there-
fore, be the basic philosophical stance of the individual or group. The radical Chris-
tian philosophy, or the philosophy of the Cosmonomic Idea, is taken as an example
to show the influence of its basic tenets on nursing ethics.
Very briefly, the cosmos, with man as its crown, is seen as having the holy will of
the Creator God as origin. This cosmos is a coherent totality of identity structures,
which include all sorts of things: plants, animals, and men. All these structures ex-
hibit a number of modal aspects. The law of God for the cosmos is the boundary be-
tween God and creation. The cosmos was created by God unto Himself and, there-
fore, the essence of all creation is its relationship to God - the religious dimension.
The cosmos has four dimensions: the religious dimension, which is the central
depth dimension concentrated in the heart of man; the time dimension; and the di-
mensions of modalities (or aspects) and identity structures. Fifteen modalities have
been identified, each of which has a unique meaning kernel. The first six aspects are
called natural aspects, because their laws are natural laws to which everything is
subject without choice. The rest of the aspects are called normative aspects, because
man has a choice to obey or to disobey its laws (norms) (see Fig. 1). Modalities are
mutually irreducible: they are governed by the principle of sphere sovereignty, that
Fig.i. Modal dimension

226 L.R.Uys
Pistic - Firm assurance
Ethical - Love
Juridical - Justice
Aesthetic - Harmony
Economic - Frugality
Social - Social intercourse
Lingual - Symbolic meaning
Historical - Formative power
Logical - Analysis
Psychic
- Sensitivity (feeling)
sensitive
Biotic - Life ( vitality)
Physical - Energy
Kinematic - Continuous motion
Spatial - Continuous extension
Numerical - Discrete quantity

Fig. 2. Modal structure
is, the laws of each aspect are sovereign within its own boundaries. But they are also
all connected by the principle of sphere universality. This principle calls attention to
the fact that each aspect mirrors all the others through analogies (anticipations and
retrocipations) drawn between them. In every modal sphere two sides can be distin-
guished (Fig.2). On the one side there is the law or norm which is peculiar to this
modality; on the other, there is whatever is subject to this law or norm.
2 Ground Motives
In this system the whole of man's functioning, including his scientific endeavors, is
seen as emerging from a fundamental, religious ground motive. A ground motive is
the central, pretheoretical preconception of a person, which is concentrated in his
heart. This merely means that no person (or scientist) can think other than out of his
heart (his self or being), which is pretheoretic.
A number of ground motives active in Western thought have been identified,
starting with the Greek motive and then the scholastic motive. The most pervasive
ground motive of our time, however, is the humanistic ground motive. It is a dialec-
tic motive with the two poles being nature (or the science ideal) and freedom (or the
personality ideal). It assumes that man is autonomous and free through mastering
The Implication of Radical Christian Philosophy for Nursing Ethics 227
nature with the help of science. The inner contradiction between the ruthless deter-
mination of science and the freedom of man leads to a continuous vacillation be-
tween the two poles. In ethics we have very good examples of people representing
each pole. Skinner [4] represents the science ideal. He says that there is no inherent
right or wrong; these are just terms we use to shape the behavior of people.
Freedom and dignity ... are the possessions of the autonomous man of tradition-
al theory, and they are essential to practices in which a person is held responsible
for his conduct and given credit for his achievements. A scientific analysis shifts
both the responsibility and the achievement to the environment [4, p 30].
Science reigns supreme. At the other extreme is Fletcher with his situational ethics
in which autonomous, rational man is free to decide for himself without legalistic
rules [2]. In the writings of some ethicists both poles are represented. Moore, for in-
stance, tries to make a synthesis between facts (science) and values (freedom) [3].
The Christian ground motive is that of creation, fall, and redemption through
Jesus Christ and the Holy Spirit. The influence of this ground motive is firstly that
the Creator God has laid down a cosmic law for order in His creation, and this was
not changed by man's fall into sin. Thus Christian ethics may never be allowed to be
relativistic. The fall into sin, however, ~ant that on the factual side of creation,
man can be faced with collision of duties. This means that in a certain situation both
options open to a person may be wrong (sin). Redemption means that forgiveness is
available through Jesus Christ and guidance in each situation is available through
the Holy Spirit.
In an ethical argument, the ground motives of the different positions have to be
analyzed. This process is called transcendental criticism and is essential to under-
standing and evaluating different ethical systems.
3 The Ethical Modality
Ethics has often been equated with normative behavior - what man ought to do.
From this scheme of the modal dimension (Fig. 1), it becomes clear that not all nor-
mative behavior falls within the ethical realm. There is also behavior that is logically
right or wrong, linguistically right or wrong, or economically right or wrong. This
does not make all these behaviors ethical in nature. Ethics can thus be defmed as
the science which identifies the ethical modality and differentiates it from other
aspects. This includes identifying and describing its meaning kernel (love), its antic-
ipations and retrocipations, a,s well as situationally and structurally typical norms.
If the ethical aspect is not given its rightful place, one of three things can hap-
pen: the ethical can be reduced to some other aspects, repudiated, or over accentu-
ated.
3.1 The Ethical Can Be Reduced to Some Other Aspects
Quite a few examples of this reductionism can be identified. The naturalistic ethics
of Rousseau (and Freud), which defines right as being that which gives the natural
aspects free reign and restricts the normative aspects, reduces the ethical to the nat-
228 L.R.Uys
ural aspects. Historicism, which sees right as those norms which have developed
through certain historical processes and for certain groups, reduces the ethical
aspect to the historical aspect. Ethical emotivism, which defines right and wrong as
emotions elicited by certain actions, reduces the ethical to the psychic aspect.
3.2 The Ethical Can Be Repudiated
The existentialists (Heidegger, Jaspers, Satre, and de Beauvoir [1]), with their strong
focus on existence, are not interested in the essentials of the ethical. Simone de
Beauvoir talks about a morality without content, because when a definite content is
ascribed to the ethical, the "freedom" of man is curtailed by "what should be." This
viewpoint denies the ethical aspect of man's nature.
3.3 The Ethical Can Be Overaccentuated
When the ethical norm of love is allowed to spill over its borders and to encroach
into the sphere sovereignty of other aspects, disharmony ensues. The strong focus in
the health world of today on the rights of man, without considering his responsibili-
ties, is an example of such a overaccentuation of an ethical norm [5].
Disturbing the balance among the different parts within the modal structure of
the ethical also leads to different "isms": denying the norm side leads to relativism,
overaccentuating the subject leads to subjectivism, and overaccentuating the factual
side leads to irrationalism.
4 View of Man
Christian philosophy believes that God created man after His own image. Man's
existence is concentrated in his heart, which is premodal, prestructural, and eternal.
Man's body has four structures which are interwoven without each strand losing its
own characteristics: a normative, typically human, personality structure; a psychic
substructure; a biotic substructure; and a physiochemical substructure. These four
structures make an indivisible whole: the soul-body dualism is rejected for the sake
of a duality. (The question of when ensoulment takes place, which is so important in
abortion arguments, thus does not arise.) God placed man in the center of the uni-
verse and gave him a cultural mandate to cultivate and rule over the earth.
Man is a normative being. This means that he was created with the free respon-
sibility to positivize creation principles into norms. A principle refers to the origin or
source of something. Cosmic principles are the modal and structural preconditions
for human existence. Man can never withdraw himself from them - he cannot be
"a-ethical" or "a-biotic." Cosmic principles must, however, be positivized (or
concretized) by man into norms. Positivization is free form-giving by a human being
on the ground of discriminating formative authority (capacity) and is dependent on
the stage of cultural development. A norm is a rational, temporal standard of what
ought to be. When a norm is obeyed, a value is realized. Values are acts, events, con-
The Implication of Radical Christian Philosophy for Nursing Ethics 229
crete, and products of norms. "Values are referential in character and only in this
reference to the law-order do they possess any meaning" [3 p 187].
This dynamic relationship among cosmic principles, man, and norms makes it
clear why no casuistic list of rules can be acceptable as an ethical system. The nurse
has to take the ethical principle of love, study the structures and situations in which
she is placed (these include her culture, the health care system, her profession, the
legal system, and the client system), and responsibly positivize norms which are his-
torically relevant. She must realize that norm variability is a retrocipation to the his-
toric aspect and does not mean that she is being relativistic. She must also remem-
ber that when she is working with human beings, their normative and eternal nature
must be respected. Of course there will be chaos if every nurse does this individual-
ly, but groups should get together for this task.
It is impossible to make well-grounded ethical decisions without first taking an
in-depth look at one's own view of man.
5 Conclusion
This presentation of the philosophy of the Cosmonomic Idea was given to show the
far-reaching influence that the basic philosophical stance has on ethics. Although a
study of philosophy to find a system with which one feels comfortable may sound
like a tall order, I believe that nursing science can no longer accept a prescientific
intuitive approach to its ethical problems. We must take time to give nursing ethics a
solid philosophical foundation.
References
1. de Beauvoir S (1967) Humanistic existentialism: the literature of possibility. University of Ne-

braska Press, Lincoln
2. Fletcher J (1967) Situation ethics. C. S. M., London
3. Olthuis JH (1969) Facts, values and ethics. Van Gorcum, Assen
4. Skinner BF (1971) Beyond freedom and dignity. Penguin, New York
5. Van Den Berg JH (1969) Medische macht en medische ethiek. G. F. Callenbach N. V., Nijkerk
v. Epilogue
Introduction
When the nurse practitioner became a more independent person, leaving the pro-
tective and overpowering shadow of the medical doctor, rights as well as obligations
were gained. Not all treatment settings are uniform in this newly developed depen-
dence-independence model; institutions, hospitals, homes etc. each have their own
very different ways of dealing with this issue.
An interesting concomittant issue that arises with the autonomy and greater re-
sponsibility that nurses have attained is the moving-up the ladder of responsibility
and hierarchy by paraprofessionals and practical nurses. These workers are now as-
suming a greater role in clinical nursing.
The papers in this section, from Israel and South Africa, look at the nurse practi-
tioner in relation to the "self' as well as the "other" - in regard to dependent, inde-
pendent, and interdependent functioning. This section ends the book with provoca-
tive questions with regard to health care resources, on what basis are services
allocated, and ethical determinations for receiving/giving care.
The Dependent, Independent and Interdependent Functions
of the Nurse Practitioner: A Legal and Ethical Perspective
C.Searle
1 Introduction
In general, contemporary nursing literature from Western countries does not take a
bold stand on the very controversial issue of the dependent and independent func-
tions of the nurse practitioner. The authors write as if they are skating on very thin
ice. Textbooks on nursing imply a great deal about the practice potential of nurses
but ever and anon there is a subtle reversion to the concept that nursing has certain
dependent functions, meaning functions that require a doctor's authorization, and
certain independent functions that are carried out on the nurse's own initiative and
responsibility. In general the majority of authors consulted appear to subscribe to
the concept postulated by Sarney when he says: "A good nursing practice act will
separate the independent functions (what a nurse can do on her own) from the de-
pendent functions (what she can do only, under the direction of a doctor)" [6].
I question this standpoint. We are living in an era of multidisciplinary teamwork
in the health field. In this team the patient is the leader of the team, not the doctor,
although the doctor has certain, specific levels of expertise that other members of
the team do not have and, in consequence, makes the major diagnostic and thera-
peutic decisions. These decisions have largely to be implemented by other members
of the health team. In this sense he then "assumes direction" of the total health care
program. Yet, in my country at least, there is no law that says he is the leader, for
chiropractors, psychologists, osteopaths, nurses, and midwives all have the legal
right of practice. All these professionals may call the doctor in to share the decision-
making process, treatment, and care of their patient. In some cases he may refuse to
do so.
2 The Question of the Dependent, Independent and Interdependent Functions

oftbe Nurse
It is precisely this position that raises the question of the dependent function of the
nurse being one that is dependent on the doctor.
I believe that the functions of the nurse should be described as dependent, in-
terdependent, and independent, with a shift in the traditional meaning of the depen-
dent function.
The dependent function of the nurse is based on the law which authorizes her
practice and on common law and relevant statutory laws. It is not based on that
which the doctor prescribes, requests, or directs for the patient. In accepting such
direction or prescription the registered nurse acts as a professional person and is re-
sponsible and accountable for her own acts and omissions.
Without the observance of the provisions of the nurse practice act, she becomes
236 C.Searle
criminally liable and without the observance of other health-related legislation she
may become civilly or criminally liable. The law is the system of rules that provides
order in professional practice. It is the law, and only the law, that authorizes her pro-
fessional acts. She is dependent on the law for every aspect of her professional role
and function. I must emphasize that the locus of the dependent function of the
nurse is, and remains, the law empowering her to practice. This includes the regula-
tions made by the subsidiary legislative authority, namely, the professional registra-
tion and controlling authority (in my country, the South African Nursing Council).
It further includes decisions given by the courts anent the interpretation of such
laws.
The interdependent function relates to the interrelationship of the nurse with the
patient and with other members of the health team. In particular it relates to the in-
terdependence of nursing and medicine. The nurse, whether as institutional practi-
tioner or as private contractor, is not the servant or subordinate of the doctor. She is
a registered nurse practitioner, entirely responsible and accountable for her own
acts and omissions to the registration authority, the South African Nursing Council,
and in the broader sense, to the courts. Where she accepts a prescription, request, or
direction for treatment of a patient from a doctor, she does so as an independent
practitioner on behalf of her patient and she has a shared responsibility with the
doctor. She acts in the interests 0[. her patient and in so doing has a joint responsibil-
ity with the doctor for ensuring that the patient is receiving the prescribed diagnos-
tic and therapeutic care as well as the relevant nursing care. In other words, the pat-
ient is her patient as much as he is the patient of the doctor. She cannot distance
herself from this elementary fact. Doctor and nurse have an interdependent and re-
ciprocal responsibility. Neither can provide all the health care the patient needs. It
is a joint as well as a broader team effort. In this respect a very substantial element
of coordination of team activities is done by the nurse in the interest of the patient.
The interplay of activities between doctor and nurse epitomizes the interdepen-
dence of their functions.
The interdependent function is clearly recognized in the various health profes-
sional registration acts and in the regulations made thereunder. It is interesting to
note that in South Africa, interprofessional cooperation is limited to those profes-
sions that are duly registered or enrolled under Act of Parliament, that is, those that
are dependent on legislation for their practice. Within these parameters all partici-
pants in any patient care situation have mutually interdependent, but also indepen-
dent, functions. Throughout such interdependent action the nurse remains respon-
sible and accountable for her professional acts of commission or omission.
The independent function of the nurse has two dimensions. One dimension re-
lates to all those aspects inherent in nursing diagnosis, treatment, and care which
are the normal prerogatives of the nurse. The other dimension is concerned with the
manner in which she carries out any of her duties as a registered nurse, whether this
be an independent or interdependent function. Whatever she does, she does on her
own responsibility and accountability, for in law she is personally liable for her acts
of omission or commission. She and she only remains accountable for her actions.
Only she can decide whether she is legally able, or knowledgeable and competent
enough, to accept a specific prescription or direction from a doctor or is able to par-
ticipate in the care provided by other members of the health care team. Once she
The Dependent, Independent and Interdependent Functions 237
has indicated acceptance she has made an independent decision and accepts full re-
sponsibility and accountability for her decision and actions. Even her decision to
observe the provisions of the nurse practice or related laws is an independent func-
tion for which she is personally responsible and accountable. It is important to note
that neither the nurse nor the doctor nor any other member of the health team is an
autonomous practitioner, for such a practitioner does not exist. All the members of
the multidisciplinary health team are responsible and accountable to the patient,
the registration authority, and the law of the land, which is the vigilant sentry before
the door of everyone's professional life. All are accountable, and if one is accoun-
table one cannot be autonomous, be one doctor, nurse, psychologist, social worker,
physiotherapist, or any other member of the health team.
The nurse is solely responsible and accountable for her own practice whether
this be in a fee-for-service situation orin a salaried situation where she has to accept
responsibility for a number of patients. This is the basis of her professional practice
in South Africa. Her independent function supersedes and indeed pervades her in-
terdependent function (South African Nursing Council Regulations, 1950).
From where does she derive this authority, this delineation of function? These
three functions are squarely based on the law governing the practice of medicine
and of nursing in South Africa and on le~al decisions which have been given by the
courts in law suits involving patients, doctors, and nurses [5]. Without such laws and
legal decisions, professional practice for all health professions would be chaotic.
These laws are not a restriction upon the freedom of a professional, but a gateway
to greater freedom, for they establish certain rules that the health practitioner may
not transgress. These laws are made to free the professional, not to bind him, by tell-
ing him what he may do without transgressing on the equal liberty of other health
professionals.
3 Exclusive Right of the Doctor to Clinical Responsibility Not Established in Law
In South Africa, the Medical, Dental, and Supplementary Health Service Profes-
sions Act 56 of 1974, as amended, governs the practice of medicine, dentistry, psy-
chology, and the supplementary health professions. Nur~ing, midwifery, pharmacy,
and chiropractic are not supplementary health professions. They are professions in
their own right with their own practice acts. The Medical, Dental, and Supplemen-
tary Health Service Professions Act prohibits any person who is not registered as a
doctor, excluding persons registered under the Nursing Act and the Chiropractors
Act, performing any act whatsoever having as its object the diagnosing, treating, or
preventing of any physical (including mental) defect, illness, or deficiency in any
person, including the giving of advice in regard to such defects, illnesses, or defi-
ciencies, or the prescribing or providing of medicine in connection with such de-
fects, illnesses, or deficiencies (the Medical, Dental, and Supplementary Health Ser-
vice Professions Act 56 of 1974, Section 36).
Provision is also made in the Nursing Act setting out under what circumstances,
which are not emergency situations, nurses may be authorized by the Nursing Coun-
cil to prescribe and provide scheduled medicines or to prescribe and provide medi-
cal treatment (as distinct from nursing treatment and care and as distinct from emer-
238 C. Searle
gency health care) in the absence of a doctor or pharmacist (Nursing Act 50 of 1978
as amended by Act 71 of 1981, Section 38 s). The extensive gray areas between nurs-
ing and medicine where there is overlapping of the functions which can be per-
formed with varying levels of knowledge and skill is thus duly recognized in law.
In a free enterprise health care system, such as exists in South Africa, the law
and its regulations impose certain limits of action upon both doctor and nurse. Both
may charge fees for patient care, but neither practitioner is free to charge the patient
an unlimited fee that he or she may wish to impose. The maximum fees chargeable
in private practice are prescribed by the Medical and Nursing Councils respectively.
Neither may such practitioners "enter into an agreement whereby the patient un-
dertakes to assume responsibility for negligent treatment" [10 p 317]. All registered
health professionals, including the doctor and the nurse, are not only dependent on
the laws and regulations authorizing their practice but within the ambit of their pro-
fessional code of ethics cannot perform professional acts for which they are "not
adequately trained and/or insufficiently experienced except in an emergency" [11].
Common law is explicit in this regard, namely that "a practitioner who performs
such acts may be held liable for damage or injury suffered by the patient in conse-
quence there of on the basis of negligence" [11]. This is a very powerful inducement
to responsible action in which the practitioner has the independent function of per-
sonal responsibility and accountability. Nothing in an agreement between doctor
and patient requires the doctor to provide all the care the patient needs, for clearly
in the multidisciplinary team context, and in the very nature of modern total care,
this is unthinkable. The doctor cannot and does not have sole clinical responsibility
for the patient.
In a country with a well-regulated health practice system, some authority has to
authorize practice and assign responsibilities. In South Africa, this is done by Par-
liament, which enacts legislation for the regulation of the various professions in the
interests of the public [10 p 9], and on this legislation the professional is dependent.
4 Nurses Must Take a Stand on the Meaning of the Dependent,

Independent and Interdependent Functions
For most of nursing's long history there is evidence that nursing has always hadthis
three-dimensional basis of practice. Let me try and sketch this assertation.
4.1 17re 11rree Functions in Preliterate Society

In preliterate societies the locus of authority for any action relating to a member of
the family rested with the head of the family and through him to the extended fami-
ly, the clan, or the tribe. This was from where the dependent function stemmed,
namely, the law of the head of the family. The independent function related to the
care provided by the responsible family member who had to exercise great respon-
sibility and accountability in carrying out such care. The interdependent function
was very much to the fore, for within the particular social pattern, the provider of
care had very definite interdependent responsibilities with other members of the ex-
tended family or clan and with the traditional healer.
4.2 In Early Hebrew Society
These selfsame functions are epitomized in the early Hebrew period by the legal
and ethical stance adopted by the midwives Sephra and Phua who disregarded the
injunction of the Pharaoh that they had to kill all the newborn male infants born to
the people of Israel. Awareness of the temporal laws of Egypt, but utter obedience
to the laws of Jehovah, close interdependence with the leaders and teachers of their
people, and independent action by the midwives characterized the actions of these
midwives (Exodus 1: 15-21).
4.3 The Hippocratic Period
We see a new development in the Hippocratic period where there appears to be a

shift away from this approach. Shryock quotes a translation which indicates the
need for, and the position of, the nurse with reference to instruments used in an op-
eration. "But if another gives them he mllst be ready a little before hand and do as
you direct" [9]. Clearly this indicates a position dependent on the physician. It has
not been possible to trace what the measure of responsibility and accountability was
in such cases. It appears that the physici'an assumed an all-powerful role. I may be
wrong in my deductions.
4.4 The Early Christian Period
The monastic, crusader, military, and secular nursing orders were all dependent for
the provision of health care on canon law, or the laws of the church, and the rules of
the respective orders approved by the church. These orders all acted on the Chris-
tian ethic, as exemplified in Christ's teaching that identified the love of one's neigh-
bors with the love of God in his promise that "inasmuch as ye have done unto the
least of these my brethren, ye have done it unto me" (Matthew 25: 40). With the
words "I was sick and ye visited me" (Matthew 25: 36) nursing was lifted to a plane
of moral obligation and an ethical tradition was born. The locus of authority was
canon law, on which the dependent function of the nurse was based. A very strict
interdependent function existed with other members of the religious order who
shared patient care and with the priests for spiritual care, but within these parame-
ters the provider of nursing care had the independent function of diagnosing, pre-
scribing, and providing treatment and care, and of ensuring that her interdependent
functions were carried out within the dictates of the policy of mother church. For all
this she was held responsible and accountable to the superiors of the order and to
the mother church. The above pattern also flourished in feudal times when the lady
of the manor provided care within identical parameters.
Throughout the long history of the Christian church, the men and women who
carried the Christian faith and Westernized healing services to all comers of the
earth provided nursing within these parameters. Common law apparently made
little impact on their practice. Canon law was the foundation on which they built: it
was their sole source of authority. It was the nineteen and twentieth century devel-
240 C. Searle
opments that highlighted the common law components of practice and brought
statutory foundations for the practice of nursing and medicine.
In all these periods of nursing history, except perhaps in the Hippocratic period,
accountability was a well-entrenched concept. Sanctions of some kind or other al-
ways existed and could be imposed on those who failed in their accountability.
4.5 The Dark Ages in Health Care
The eminently logical and orderly system of health care provided under canon law
fell into disuse at the time of the Reformation, when the care of patients was wrest-
ed from the hands of the great religious orders. Felons, indigents, drunken slatterns,
even other patients provided such care as existed in the Poor Law institutions.
Chaos in the institutionalized care of the sick threw the functions of the provider of
nursing care into disarray, with no clear distinction between the functions of a nurse
and the functions of the lowest grade of domestic servant.
4.6 The Nightingale Era
When Florence Nightingale came on the scene in her struggle to reorganize hospi-
tals and health care systems, and workintas she did within a military system, she
totally sacrificed the potential legal functions of the nurse "to the orders of the doc-
tor," i. e., to the military orders of a military officer. She required total dependence
and absolute obedience to the doctor within a military hierarchical system. More-
over she required the submissiveness akin to thaf of the religious sister as well as the
unquestionable obedience of a person in the military system who was subordinate
to the officer class. To enforce respectability in nursing she had to require rigid ob-
servance of military discipline and orders. In the process she undermined the pro-
fessional development of nursing, even after legislation was enacted for registration
of nurses and the nurse was given a legal role of her own. She started the concept of
the nurse having a function dependent on the doctor. With the wisdom of hindsight,
we lay this accusation at her door, forgetting that we, who have lived in an era of
professional registration of nurses, have happily perpetuated this myth. Our sin is
the greater!
The pernicious concept of the function of the nurse being dependent on the or-
ders of the doctor was carried to every part of the world where the Nightingale sys~
tern penetrated. By five words "the orders of the doctor" uttered in a male-dominat-
ed, Victorian, military milieu, nursing practice was denied its legitimate profession-
al rights and responsibilities for many decades. In some parts of the world this
concept still persists. '
4.7 The Nurse as the Tool for Reorganization of Hospitals
In the struggle to reorganize hospitals and to keep the costs of this as low as possi-
ble, the nurse was made the tool for such reorganization. Her own professional
rights and responsibilities were ruthlessly denied her, even after legislation was en-
acted enabling her to be a professional practitioner in her own right with only one
source for the dependent dimension of her practice: the law.
The training system ensured that a docile, brainwashed, manageable person, ill-
equipped to fight for her professional rights, provided the cheap yet disciplined and
well-skilled service that enabled hospitals to exist, medical schools to flourish, and
medical practitioners to grow prosperous on the sweated labor of the nurse. The
myth that the nurse is dependent on the medical practitioner for the authorization
of her practice, and that she is subservient to him, persists despite legislation to the
contrary. This approach resulted in the nurse seeking power and authority in the ad-
ministrative system of the health servive. She relegated the all-important clinical
function, which is basic to the authorization for practice, to a secondary place. Evi-
dence of this abounds around the world. Until the nurse recognizes the error in this
approach she will not understand the thtee-dimensional nature of her function and
will not appreciate the vital importance of her dependent function that has its locus
in the law.
5 First Professional Registration of Nurses Located the Dependent Function

of the Nurse in the Law
The very first legislation in the world to recognize nursing as a profession and to reg-
ister nurses was enacted by the Parliament of the Cape Colony (now the Cape Prov-
ince of South Mrica) on 21 August 1891. This Act (the Medical and Pharmacy
Act 34 of 1891) provided for the registration of nurses and midwives on the same
register as medical practitioners, dentists, pharmacists, and druggists. It provided
such basic principles for the registration of a professional person as training, exami-
nation, certification, registration, disciplinary control, recognition of further study
and qualification, protection of the rights of persons registered, as well as the pro-
tection of the public to be served. This law and its relevant regulations provided for
the cancellation of certificates and the withdrawel of the right of practice for in-
competence, negligence, acts of omission and commission, and conduct unbecom-
ing to a professional person. All this required an independent function and ac-
countability.
Despite the fact that the law clearly delineated the nurse as a separate category
of practitioner, responsible for her own conduct and practice, the myth persisted. I
believe the myth persisted for an ethical reason that had a very heavy overlay of eti-
quette. The nurse makes a commitment to patient care that goes beyond her own
feelings. She subscribes to both the negative apodosis of primum nocere, doing no
harm to the patient, and the positive protasis, ensuring benefit for the patient. These
have their origins in the Hippocratic concept of being helpful and doing no harm.
In the quasi-religious, quasi-military atmosphere of the reorganized hospital ser-
vice, the nurse was enjoined to observe the strict etiquette of acknowledging the se-
242 C. Searle
niority of "the medical officer." In time she saw this as an ethical obligation, deny-
ing her legal dependent function and her own independent function in the process.
Nevertheless, in the de facto situation she adroitly exercised her independent func-
tion without raising any dust about it. It took several lawsuits in South Mrica, as
well as the establishment of the South Mrican Nursing Council, through the enact-
ment of the Nursing Act 45 of 1944, to bring it home to the nurse that only the said
Council, empowered by the law, can determine what her practice is, and that she is
personally responsible and accountable for how she exercises her dependent, inde-
pendent, and interdependent functions. This is slowly being recognized by the doc-
tor and the nurse, but such change is long-drawn-out, for it is part of the overall so-
cietal change in my country.
Professional Legislation in South Mrica
- The Medical and Pharmacy Act, 34 of 1891
- The Nursing Act, 45 of 1944
- The Nursing Act, 50 of 1978 as amended by Act 71 of 1981
- South Mrican Nursing Council Regulations - Acts and omissions of registered
nurses. G N 1650 of 14 September 1972 ad amended by G N 481 of March
1978:1
- The Medical, Dental, and Supplementary Health Serivce Professions Act, 56 of
1974 as amended
- The Chiropractors Act, 76 of 1971
- The Homeopaths, Naturopaths, Osteopaths, and Herbalist Act, 52 of 1974
- The Pharmacy Act, 53 of 1974
- Miscellaneous Acts relating to the provision and control of health services, medi-
cine and drugs, abuse of dependence-producing substances, hazardous sub-
stances, organ and tissue transplants, birth, marriages, and deaths, abortion and
sterilization acts.
References
1. Andrews WA (1896) The doctor in history, literature and folklore. Andrews, Hull (Reprinted by
University Microfilms International Ann Arbor 1981)
2. Fenner KM (1980) Ethics and law in nursing. Van Nostrand Reinhold, New York
3. Martin AJ (1976) Duty of care. Nurs Times, 9 Sept 1976: 1379
4. Mead, Hurd KC (1937) A history of women in medicine. Haddam, Connecticut (Reprint B VI
Longwood Press 1979)
5. Nathan (1957) Medical negligence. Butterworth, London, pp 61-101
6. Sarney H (1968) The nurse and the law. Saunders, Philadelphia, p 18
7. Searle C (1965) A socio-historical survey of nursing in South Africa, 1652-1960. Struik, Cape
Town
8. Searle C (1980) The wardsister - some aspects of her role and function. Curationis, V 3: 1 : 6
9. Shryock RH (1959) The history of nursing. Saunders, Philadelphia, p 53
10. Strauss SA, Strydom MJ (1967) Die Suid-Afrikaanse Geneeskundige Reg: Van Schaik, Pretoria
11. Strauss SA (1981) Legal handbook for nurses and health personnel, 4th edn. King Edward VII
Trust, Cape Town, p 4
12. Thompson JB, Thompson HO (1981) Ethics in nursing. MacMillan, New York
The Changing Role of Nurses and Its Implications
D.Michaeli
Nurses resent the image of "physicians helpers" as still seen by the public in gener-
al. They demand to assume partnership in responsibility for decision-making con-
cerning patient management. In England in a paper in the British Medical Journal
the author says such decisions are made only by physicians and social workers
while other professions, including nurses are devoid of the possibility to interfere
[1].
One attempt Sit changing this situation was made by replacing older nurses with
younger nurses. Since such nurses did not have enough experience to be able to
acquire on informal influence, they put the emphasis on administrative (bureaucrat-
ic) intervention rather than on clinical nursing, and their influence on the decision-
making progress was small.
In the United States the notion of "the nursing process" was developed. This in-
cludes: evaluation of the patient's needs, planning the management, performing the
nursing itself, and evaluation of success. 'The process starts by taking a "nursing pat-
ient's history" and the nurse is personally in charge of the patient for all the man-
agement. Many nurses resent the amount of paperwork which is involved. But,
there is a general trend with the more influential leaders among nurses to give the
nurse the responsibility for establishing standards and more authority. This of
course goes along with the question of the nurse's accountability for her deeds and
her decisions, being more independent of the "coverage" of the physician.
The problem of the nurses who struggle to achieve a status equal to that ofphy-
sicians is a real one. Nursing is establishing itself as an academic entity with masters
degrees and doctorates in nursing. Such graduates tend to achieve that status which
they "deserve."
Nursing is struggling to develop its own theory and practice and its own re-
search. Nurses now openly claim their right to assure the role of head of health
teams. While they do not look upon themselves as a "subentity under medicine, "they
claim their independent status and power similar to other academic professions.
While nurses themselves realize that nursing as an academic profession is not
yet ready to assume this status and responsibility, they believe that "medicine"
should learn to live with the idea of complete equality in status and power and ad-
just itself to a new situation [2].
I wish to challenge the nursing profession and to suggest that this trend carries
within itself the very seeds of the troubles which when growing-up will be counter-
acting these idealistic and simplistic attitudes of those deans of nursing schools and
other leaders of nursing who, in their enthusiasm, disregard realities of the health
delivery systems.
I really do not object to any nurse or any other health professional who wants to
be responsible for clinical care of patients. If they want to assume full responsibility
for diagnosing and treating patients, they should study medicine, get the license,
and do it. I really don't believe there is either a place or a need for a parallel devel-
244 D. Michaeli
opment of nurse-healers. This does not mean that nursing as such should not devel-
op its own research, theory, and practice. I really believe that "academization of
nursing" is a fact and the problem now is to try and study what should be the future
of this nursing profession and in what direction it should develop. It is not just a
game of power and politics. It is too important to leave it at this level.
The trends to nursing are in many ways similar to those seen in medicine and
they are the result of technological development and over-specialization. Once the
academic nurse is qualified she should either develop and progress with science and
technology or be lost and deteriorate and loose her status. The result is a detach-
ment of the nurse and her drifting away from many traditional roles and tasks,
which do not satisfy the ambitions of the sophisticated modern nurse. This creates a
vacuum that is already being filled by nonregistered "nurse aides." On the other
hand "intensive care nurses" and other specialist nurses create a new problem. Ifwe
say that in a general hospital up to 8% of the beds are intensive care beds, they need
(in Israel) 24% of the nurses of the hospital. We are already incapable of supplying
this number of qualified specialists and we drain too many qualified nurses from
the general wards to these units. Can we go on like this? The answer is "no" and the
solution is to create new professions of "physician-helpers" (like "physician assis-
tants" or "paramedics" and other "health technicians") who will eventually replace
the traditional nurse, while the qualified nurse will be directed toward the more in-
teresting jobs in patients' care.
The nursing profession is fighting against this trend but does not offer any solu-
tion. Nurses fight this battle on a pure "professional-labor-union" basis with a lot of
"cotton-wool jargon" and demagogy and little substance. Yet, if nurses don't want
to understand it and adjust to reality they will soon be faced with a new world they
may not like at all, but with which they will have to live.
In the nonsophisticated health systems like geriatric or psychiatric institutions,
there is little room for the academic nurses and very few such nurses will find their
place there. This is going to be a vacuum again and will be filled in by other people
who will develop a new health profession of physicians helpers. So if nurses don't
like to act like physicians helpers they must think about who is going to assume this
role in the future, because these professions will take the place of the nurse. It may
be called "hCIpers," "aids," "technicians," "paramedics," "physician assistants," or
any other name, according to their formation, preparation, education, and role, but
in fact they are already here with us and they are going to stay.
Another problem for the nurses to cope with is the polarization within the nurs-
ing profession. The general ward nursing leader (graduate in nursing) will be differ-
ent from the intensive care nurse specialist and both will be different from the nurse
in the outpatient clinic. The nurse in public health has drifted away even more from
the general trend of the technological nurse specialists and I can see the day when
these nurses will try to separate themselves from the main corps of nurses.
I suggest, therefore, that the academization of nursing opens many paths for the
development of a new breed of ambitious technocratic nurses. But it creates a
severe vacuum in many areas which traditionally belong to nursing and tomorrow
will be going to new health professions. These developments are bound to create
polarization and tensions within the nursing profession (such as we observe in med-
icine!) and the challenge facing the nursing profession is to cope with these trends
The Changing Role of Nurses and Its Implications 245
and developments. I believe the chance that nurses will assume the responsibility of
physicians in regards to clinical work are negligible but the dangers to the nursing
profession are very real.
My question to the nurses is, are you ready for this challenge [3]?
References
1. Editorial (1981) Doctors and nurses. Br Med J 283: 683-684

2. Peterson CJ (1982) The new nurse and the new physician. Ann Intern Med 96: 374-375
3. Michaeli D (to be published) Physicians, nurses and all the others. Harefuah (Heb.)
Subject Index
advocacy 126 feeding 197 procreation 61

attitude 144 professional 30, 94, 241, 244
authority 9,45,62 game 165 prosecutors 82
autonomy 28
harm principle 61,65 research 115, 122, 126, 132,
care 171,188,191,205 Holocaust 22 136
charity 3 responsibility 9, 14, 30, 94,
christian 225 illness 210 193
clinical 136, 237 incest 75 rights 14, 22, 30, 45, 56, 61,
clinician 82 informed consent 67, 138 193
code 158, 182 integrity 31
colleagues 30 invohmtary 61 secrecy 52,74
computerization 74 sex 4
confidentiality 70, 139 Jewish 216 sick 216,220 .
contracts 30 socialized medicine 191
law 98 social status 6
decision making 151, 160, 165
leadership 35 standards 32, 39
defenders 82
legal 39, 51, 54, 56, 235 sterilization 61
dignity 185
stress 210
dilemmas 93,151
malpractice 45 surgery 54
dying 184
mentally ill 56
education 8 mentally retarded 61 teaching 105
elderly 191 ministering 220 terminally ill 144
ethical 136,145,151,160,165, moral 56,93 training 109
178,184,188,191,235 truth 3, 26, 67
ethics 96, 98, 103, 115, 122, Nuremberg 22
126,132,170,216,225 weltanschauung 29
ethnographer 136 paternalistic principle 61 will 18
euthanasia 144 practice 45,132 witness 39,83
Medicolegal Volume 1
Library Child Abuse

Editors: A.Carmi, H.Zimrin
Editor: A. Carmi
1984.39 figures. X, 216 pages. ISBN 3-540-12471-3
Child Abuse is the first volume in Springer Verlag's impor-

tant new series Medicolegal Library. An interdisciplinary
approach to one of modern society's most appalling pheno-
mena, it shows that child abuse is not the result of uniform
behavior patterns, but rather has many causes requiring
many different types of treatment. The contributions focus
on legal, pathologic, sexual, psychiatric, and familial aspects
of the problem and show how they are dealt with in various
Western countries.
Volume 2
Euthanasia
Editor: A. Carmi
1984. X, 185 pages. ISBN 3-540-13251-1
This second volume in the Medicolegal Library provides a

cross-cultural view of the dignity of life and the right to die.
The authors trace the phenomena of euthanasia from its
earliest recorded instances to the present and consider it
from the points of view oflaw, medicine, psychology, socio-
logy, philosophy, and religion.
Volume 3
Disability
Editors: A. Carmi, E. Chigier, S. Schneider
1984. 5 figures, 20 tables. XIV, 253 pages.
ISBN 3-540-13421-2
The authors of this third volume in the series Medicolegal

Library bring together legal, medical and psychosocial
Springer-Verlag aspects of disability to allow those involved in the care and
integration of the disabled to benefit from the experience of
Berlin others. Their contributions include such topics as problems
Heidelberg with the implementation of antidiscrimination laws,
New York compensation for chronic pain, the rehabilitation of heroin
addicts, and medicolegal problems of sterilization for the
Tokyo mentally ill.
Medicine
and Law An International Journal
ISSN 0723-1393 Title No. 346
Editor-in-Chief: Judge Amnon Carmi, P.O.Box 6451,

Haifa 31063, Israel
Co-Editors: Prof. Dr. E. Deutsch, Prof. Dr. A. Eser, Prof.Carrnen

Nathan, Prof.R. Slovenko, Prof. S.A. Strauss
Field Editors: Dr. E. R. Halsband, (Dentistry and Law); Dr. H. Hirsh,

(Medical Law); Dr.J.Money, (Sexology and Law); Dr.D.J.Milller,
(Psychology and Law); Dr. P. J. Resnick, (Psychiatry and Law);
Dr. C. Roy, (Clinical Criminology); Prof. P. Sachdev, (Child Abuse);
Prof. S. Schneider, (Medical Ethics); Dr.P.Silfen, (Clinical Crimi-
nology); Dr.J. Smialek, (Forensic Medicine)
in cooperation with an international Editorial Board.
During the last decade science - and especially medical practice -

have become increasingly complex undertakings. There has also
been an increase in related legal problems. The recent dramatic
development of medicine has given rise both to theoretical contro-
versies and practical dilemmas. Society must confront new. scientific,
economic, and legal issues and struggle with them.
Medico-legal topics have always had an international flavor. The
establishment of Medicine and Law appears vitally essential for
lawyers and physicians and for the public at large.
This international publication presents articles, court-decisions, and

legislation on:
Medical law, forensic medicine, medicine and law, psychiatry and

law, psychology and law, dentistry and law, nnrsing law, medical
ethics, malpractice, expert testimony, clinical criminology, drugs,
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Medicine and Law proves to be a source of information not easily

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Medicolegal Library 4

Prof. Dr. Stanley Schneider

ISBN-13: 978-3-540-15253-8 e-ISBN-13: 978-3-642-82468-5

Library of Congress Cataloging in Publication Data

Nursing: State, Status and Statutes

II. Nursing: Legal Aspects . 11

III. Nursing: Ethical Aspects 89

Attitude of Nurses to Euthanasia of Terminally III Patients

Decision Making . 151

IV. Nursing: Cultural and Religious Aspects .201

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

J. Rosenkoetter and M. Rosenkoetter

H. O. Thompson and J. B. Thompson

1 The Whole Truth

4 Who Is More Important?

There is no way to measure or determine the importance of nursing. Every state-

show the power of education, or if you wish, "brain-washing," which is applied at

Human Rights in the Nurse-Patient Relationship

Nearly everywhere wo look, we find a growing number of assertions of rights in pat-

1 The format of these examples is adapted from Engelhardt [3)

In response to these cases, there are four positions to be taken:

2.1 Quorum Feature

2.2 Tracing and Examining for Appropriate Metaphors and Models

A second, four-part move consists, first, in considering a viewpoint which purports

2.3 BiologicaUBiographicallSociallCognitive Distinction

A third move by J. Rachels and W. Ruddick distinguishes biological or zoological

2.4.5 Examining the Meaning and Importance of Rights

A fourth philosophical move in defense of patients' and health professionals' lim-

3 Option Rigbts and Subsistence Rigbts

1. The New York Times (1979) March 10, p22

4 I am indepted to W. Earles paper [22]

11. Lacquer W (1980) The terrible secret. Little, Brown, Boston

People sacrifice some of their autonomy by becoming patients. Therapist-patient re-

The heart asks pleasure first,

2 Professional Status of Nursing

A second characteristic of the professional nurse is acceptance of a code of eth-

3 Standards of Nursing Practice

5 The Realities of Health Care Practice

6 Cooperative Health Care Practice

Legal Implications of Standards of Nursing Care

2 Materials and Methods

1. practitioners involved in direct nursing care,

Acknowledgements. The assistance of Mr. P. Michael Sinclair, B. A, L. L. D., of the

1 Practice: Duties and Rights and Authority

1.1 The Ward Nurse

1.1.1 The Student Nurse

1.1.2 The Senior Nurse

3 The Emergency Situation

4 Legal Proceedings: Nurses in Court

1. Donoghue v Stevenson (1932) Appeal Cases, p562

1 Nature of Human Rights

2 Legalistic Conception of Human Rigbts

3 Relationship Between Legal and Moral Rights

4 Moral Offenses Against Mentally III People

5 Moral Protection of Patients' Rights

1. Kamenka E, Tay AE (eds) (1978) Human rights. Arnold, London

2 State Authority to Allow Involuntary Sterilization

2.1 Police Power Authority

2.2 Parens Patriae Authority

A third approach is for individual courts to evaluate cases in which sterilization