Selected issues in nursing ethics: clinical, philosophical, political.
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Cultural Diversity↗
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Results for “Principle-Based Ethics”
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Autonomy, discourse, and power: a postmodern reflection on principlism and bioethics.
In recent years there has been an increasing critique of the philosophically based reasoning in bioethics which is known as principlism. This article seeks to make a postmodern contribution to this emerging debate by using notions of power and discourse to highlight the limits and superficiality of this abstract, rationalistic mode of reflection. The focus of the discussion will be on the principle of autonomy. Recent doctoral research on a hospice organization (Karuna Hospice Service) will be used to contextualize the debate to end-of life ethical dilemmas. The conclusion will be reached that the discursive richness of this organization's notion of autonomy or choice, which incorporates a holistic respect for the individual and the active creation of alternatives, can provide important insights to our understanding of autonomy in bioethics. The concern is raised that if autonomy is reified as a principle outside of the context of discourse, it may only complement the hegemonic power of biomedicine.
Bioethics↗
Shifting the autonomy debate to theory as ideology.
Some feminists have been critical about the dominant conception of autonomy, questioning, for example, its conception of persons and ideal of personhood. Tom Beauchamp and James Childress (B&C), the major proponents of the dominant conception of autonomy, believe that these feminists have misunderstood their theory and, moreover, that their theory is immune to feminist attack. Their response to feminist critics, however, has been dismissive and does nothing to assuage these critics' concerns. In this paper I briefly review the state of play in this debate about autonomy, showing that B&C are not without positive rejoinders to objections raised by feminist critics. These rejoinders rest on the notion that feminist concerns are a matter of what is logically entailed by B&C's theory of autonomy and attempt to show that feminist commitments are logically consistent with that theory. However, these rejoinders are less than convincing for reasons illuminated by Cheshire Calhoun. Calhoun reminds us that feminists are sensitive to ways in which the shape of discourse is influenced by non-epistemic considerations. In particular, Calhoun draws our attention to the cumulative effect of a whole tradition of moral reasoning that focuses on too narrow a range of moral problems and too narrow an understanding of people and the human condition. B&C's conception of autonomy relies on and reinforces ideologies of the moral life created in just this way. Following Calhoun, I show that criticism of their theory as ideology is not criticism of its logical implications, but something far more damaging, something without available rejoinders.
Female↗
Misreading of bioethics, root and branch.
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Bioethics↗
Are nursing's 'extraordinary' moral standards realistic?
This paper discusses a hypothetical situation, taken from the author's book Nursing Ethics: a principle-based approach, in which a nurse feels pressured into working beyond his official span of duty. The nurse experiences a conflict between a number of obligations; to patients and clients, to his family and to himself. To which should he give greatest weight? Steven Edwards suggests the nurse's decision is a moral one, based on personal standards held by the nurse.
Ethics, Nursing↗
Spirituality and prayer research: a select annotated bibliography.
As the world has become more complex, so too have our ethical conceptualizations about it. In the 1970s, ethical theories and principle-based bioethics dominated. Then clinicians and scholars began to experience the limitations of these two approaches when used alone. In the 1980s, women's voices began to be heard through both feminist ethics and the ethic of care. In addition, virtue ethics and casuistry again gained recognition. During the 1990s and as we are about to enter the 21st century, ethics has expanded to capture the concepts of narrative ethics and spirituality. This select annotated bibliography focuses on spirituality and on prayer research.
Ethics, Nursing↗
Ethical problems of recording physician-patient interactions in family practice settings.
Recordings of actual physician-patient interactions are an important tool for family medicine education and research. Their use, however, poses two sets of ethical problems: one dealing with privacy and confidentiality, and another related to limitations upon informed consent in the context of ordinary medical care. Experience with audiotaping and videotaping led to engaging in a "principle-based" method of ethical reasoning in which problems generated by difficult cases were examined in light of both current rules or guidelines and four fundamental ethical principles. Through this approach specific policies were developed for voluntary, informed consent and for protection of privacy, while recognizing that each case must be judged in the light of the physician's obligation to do the best for each patient.
Confidentiality↗
So many ways to think. An overview of approaches to ethical issues in geriatrics.
This article provides an overview of ways to think about ethical issues in geriatrics. Principle-based approaches include deontology, utilitarianism, virtue theory, and natural law. Case-based approaches include casuistry, care, and narrative ethics. Pragmatism and feminism are methods that mesh case-based with principle-based considerations. Each of these approaches is explained and critiqued in relation to specific cases in geriatrics. The author concludes that clinical ethical decisions are optimized by considering, but not necessarily following, all of the available approaches to ethical dilemmas.
Aged↗
Casuistry in medical ethics: rehabilitated, or repeat offender?
For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.
Bioethical Issues↗
An analysis of some dimensions of the concept of moral sensing exemplified in psychiatric care.
There are few studies that focus on the interpersonal aspect of everyday ethical conflicts. Conceptual frameworks for research into ethical decision making in the health care system are mainly based on an ethic in which objectivity and principle-based thinking is emphasized, leaving the experience of concrete moral conflicts relatively unexplored. The aim of this paper is to analyze the dimensions of "moral sensing," a concept identified in an earlier grounded theory study of psychiatric nursing. Four dimensions of the concept of moral sensing, i.e., feeling, intuition, benevolence and genuineness, were synthesized by reviewing the works of past and contemporary philosophers. The analysis of moral sensing and its dimensions is exemplified by actual nurse-patient encounters in psychiatric nursing practice.
Decision Making↗
Codes and character: the pillars of professional ethics.
Historically, the ethics of a professional were the ethics of a gentleman. The social changes in the 1960s, where citizens asked for a greater voice in all affairs that affected them gave rise to formal approaches to ethics in the health fields. Principle-based and case-based reasoning have been dominant. Neither codes nor approaches based on virtue (the character of the professional) are perfect solutions in all cases, but professions are strengthened through the development and discussion of statements about ethical conduct.
Attitude of Health Personnel↗
A memo from the central office: the "Ethical and Religious Directives for Catholic Health Care Services".
In 1994, the National Conference of Catholic Bishops revised the "Ethical and Religious Directives for Catholic Health Care Services." A goal of the Directives is to maintain the moral integrity of Catholic health care institutions and to address controversies in bioethics and health care. The Directives represent a shift to an exclusively principle-based approach to moral reason. This shift threatens to undermine the very tradition that the bishops seek to protect.
Bioethical Issues↗
[Qualified particularism and affiliative virtue: emphasis of a recent trend in ethics].
This paper explores the implications for medical ethics of ethic of care. It characterizes the ethic of care in terms of two principal commitments, to qualified particularism and to the challenge to the centrality of affiliative virtue. Both of these commitments pose a much standard work in medical ethics characterizing moral judgment and responses as essentially impartial, principled and dispassionate. A care-oriented medical ethics will, it is suggested, call on us to focus on those virtues needed to sustain community and enhance effective communication and interpersonal understanding within the practices of health care. It stresses healing rather than curing as the objective of medical and nursing care; and it emphasizes the importance of trust in clinical relationship. As a methodological approach, the ethic of care highlights the limitations of principle-based approaches in guiding moral judgment and response, asserting the value of institutional narratives as guides to moral practice.
Bioethics↗
Emotions, care and particularity.
The main intention of this article is to illuminate the normative foundation of caring in nursing. I will focus on the debate between an ethics of care and an ethics of universal principles which has evolved both in nursing ethics and moral philosophy during the last decade. In spite of what a number of people have claimed, I shall argue that a care-based ethics is compatible with judgment based on universal, impartial principles. However, an ethics of care articulates other important aspects of morality and moral behavior than the justificational ones that are central to prevailing impartialist ethics. The paper explains why and how moral perception, sensitivity and emotional capacities are important for a modern professional nursing ethics. It focuses on capacities and preconditions for principle-based reflection and action by arguing that moral perception and certain emotional qualities are prerequisites for moral judgment and action. Achieving perceptual awareness and emotional sensitivity in understanding the situation and its particulars are genuine moral tasks in nursing. These qualities are essential in discovering the morally salient features of the situation. This perspective on an ethics of care also recognizes an important place to central positions in traditional nursing ethics, where developing personal qualities and altruistic capabilities have always been a fundamental normative claim.
Emotions↗
Futilitarianism: knowing how much is enough in end-of-life health care.
The concept of futility is frequently invoked by doctors as providing ethical justification for the unilateral witholding/withdrawal of treatment of marginal benefit. The term now appears in many institutional policies. Yet it provokes controversy in its application, often being characterized as an unwarranted infringement of patient autonomy. This paper explores the substance of assertions of futility and attempts to dissect out the issues commonly intertwined in appeals to the concept. An ethical analysis of its component parts is presented using a principle-based approach to derive appropriate duties of care applicable in specific scenarios. The usefulness of the concept of futility is challenged and an alternative model is offered to deal with the ethical dilemmas posed by the availability of treatments of marginal benefit.
Ethics, Medical↗
Narrative approach to ethics education for students without clinical experience.
Niigata University School of Medicine has provided three courses in which medical ethics (ME) is taught to students who have little or no clinical experience. To evoke student's imagination, we have developed a "narrative approach" to learn ME using cases. Prior to a case analysis, students are required to exchange their own life history regarding the core issues in the case. A case is presented not only in the traditional form of vignette, but also in the form of narrative. In the narrative, the case is a story composed of personal narratives, collected and edited from diaries, letters, interviews of persons involved. Our experience suggests that the principle-based reasoning using simple vignettes is often hardly accomplished by students. However, the narrative approach was found to be useful since students can: (1) gain more accurate and wide comprehension of medical and psycho-social aspects of the case; (2) grasp the nature and the history of the conflicting views among persons in the case; (3) find more easily any method for dealing with and settling problems; and (4) exchange viewpoints with patients and their family.
Autobiographies as Topic↗
Self-perception and value system as possible predictors of stress.
This study was directed towards personality-related, value system and sociodemographic variables of nursing students in a situation of change, using a longitudinal perspective to measure their improvement in principle-based moral judgement (Kohlberg; Rest) as possible predictors of stress. Three subgroups of students were included from the commencement of the first three-year academic nursing programme in 1993. The students came from the colleges of health at Jönköping, Växjö and Kristianstad in the south of Sweden. A principal component factor analysis (varimax) was performed using data obtained from the students in the spring of 1994 (n = 122) and in the spring of 1996 (n = 112). There were 23 variables, of which two were sociodemographic, eight represented self-image, six were self-values, six were interpersonal values, and one was principle-based moral judgement. The analysis of data from students in the first year of a three-year programme demonstrated eight factors that explained 68.8% of the variance. The most important factors were: (1) ascendant decisive disorderly sociability and nonpractical mindedness (18.1% of the variance); (2) original vigour person-related trust (13.3%) of the variance); (3) orderly nonvigour achievement (8.9% of the variance) and (4) independent leadership (7.9% of the variance). (The term 'ascendancy' refers to self-confidence, and 'vigour' denotes responding well to challenges and coping with stress.) The analysis in 1996 demonstrated nine factors, of which the most important were: (1) ascendant original sociability with decisive nonconformist leadership (18.2% of the variance); (2) cautious person-related responsibility (12.6% of the variance); (3) orderly nonvariety achievement (8.4% of the variance); and (4) nonsupportive benevolent conformity (7.2% of the variance). A comparison of the two most prominent factors in 1994 and 1996 showed the process of change to be stronger for 18.2% and weaker for 30% of the variance. Principle-based moral judgement was measured in March 1994 and in May 1996, using the Swedish version of the Defining Issues Test and Index P. The result was that Index P for the students at Jönköping changed significantly (paired samples t-test) between 1994 and 1996 (p = 0.028), but that for the Växjö and Kristianstad students did not. The mean of Index P was 44.3% at Växjö, which was greater than the international average for college students (42.3%) it differed significantly in the spring of 1996 (independent samples t-test), but not in 1994, from the students at Jönköping (p = 0.032) and Kristianstad (p = 0.025). Index P was very heterogeneous for the group of students at Växjö, with the result that the paired samples t-test reached a value close to significance only. The conclusion of this study was that, if self-perception and value system are predictors of stress, only one-third of the students had improved their ability to cope with stress at the end of the programme. This article contains the author's application to the teaching process of reflecting on the structure of expectations in professional ethical relationships.
Adult↗
Understanding autonomy relationally: toward a reconfiguration of bioethical principles.
Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies in the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patient's self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality.
Bioethics↗