BMJ Publishing Group

The Task of Nursing Ethics Author(s): Kath M. Melia Source: Journal of Medical Ethics, Vol. 20, No. 1 (Mar., 1994), pp. 7-11 Published by: BMJ Publishing Group Stable URL: http://www.jstor.org/stable/27717357 . Accessed: 09/07/2013 11:28
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp

.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

BMJ Publishing Group is collaborating with JSTOR to digitize, preserve and extend access to Journal of Medical Ethics.

http://www.jstor.org

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions

Journal of medical ethics 1994; 20: 7-11

The task of nursing

Kath M Melia University ofEdinburgh

ethics

Author's
This paper

abstract
raises

shall but

the questions: 'What do we expect (Is the literature ethics?y and of nursing from nursing ethics any different from that of medical ethics?' It is that rather than develop ethics as a nursing in nursing ethics should take a lead separate field writers care in making the patient the central focus of health in health ethics. The case is made for empirical work care ethics and it is suggested that a good way of setting nurses about about this is to ask practising the real suggested ethical problems they encounter.

contribution debate,

a particular that has argue nursing care to make to the ethics and health that the the contribution of need not ethics nursing or bioethics. ethics

be necessarily in contradistinction Rather, its work contact ethical perspective. beneficence experience condition, nursing

production to medical

take advantage of the fact that could a particularly close and continuing requires so contribute to with and the patients a consideration debates of the patient's Instead etc and be of discussing autonomy, rights, start at the patient could nursing in the context of ask what their

There concerned that

is a this

lack with gap

work empirical It ethics. nursing has left the

of

in is my

the

literature contention for the a rather ethics. the as the

does whatever, consideration give and would health freedom. not to be

or it stroke, AIDS amputation, to take care of a patient it mean and to his or her autonomy, rights Nursing's to create nursing a more contribution, ethics but therefore, to inject

development prescriptive This trend

of a particular Olympian has led

style a to that

way open kind of writing, of handed down focus on

particular

and this philosophers area of applied ethics nursing question: Nursing ethics. 'What ethics These should is

in turn has has issues a

to shape helped come to be known are at the heart of ethics area look of like?'

nursing difficult that

care ethics with patient/client-led In order to do this the field stands in perspective. some need of empirical work and of consideration two what as counts first, questions, currently and second, ethics what it is that we expect nursing of nursing in other words, ethics? What, is the task of body of nursing ethics. on nursing Some of the first writings ethics appeared in the United at the States turn literature of the a considerable with amount written century, being in the first or so. There was a lot not years twenty on the subject written in the 1940s and but 1950s, considerable literature has built up in the area there day. was a steady popular, argued rise on from ethical both that the Speculations to the present 1970s are becoming questions in the general and the efforts of nursing Over ethics? the last decade a

apprehend, especially in its own entity right, from medical ethics particular

if it is to be

to study as an considered

relationship care and, structure of health organisational indeed, in the hierarchy In so far as any of occupations. can autonomous claim occupation professional status a bureaucracy, and operate within medicine managed to claim lay in that it has work to and maintain of its work control is dependent

is, in some way separate or bioethics. a has Nursing with medicine within the

has

so the occupation to semi-professional status. This lay claim on medicine means that nursing, when dependence to develop to want it wishes to itself, has a tendency in uniquely activities pull away and engage nursing and debates. best only

status, professional and membership. Nursing on medical and practice

increasingly

in part can at

making could

that nursing is status professional to do with have the something increasing in ethics. interest The of nursing ethics production texts could be seen as no more than a consequence of a growing number of academic of departments Whatever the aetiology, it remains the case nursing. are now that nurses in the ethical interested plainly in an attempt to achieve dimension of health with care. Nursing a life of its own ethics and exists as a it is unlikely

press. nursing It might be

the

Key words
Nursing ethics; care; health care ethics; research.

phenomenon to go away.

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions

The

task of nursing

ethics

As

contributor for me to to

(1) suggest

to that

the

nursing ethics or

ethics has the all that is not

doctors a look nurses order, This to the ethical

literature, no right motivation that

an independent for ethical debate be

nursing existence

One these powers. exercising only has to take areas of psychiatric care (3) to see that at other a lot to do to put in have their own house before medical invading territory. draws rather military-style attention language we are dealing in with fact that much of what

within

nursing

is perhaps disingenuous. have the time has come when questions the nature and purpose of nursing about I have over the the field changed last few of my years.

it should

However, to be asked ethics.

bioethics,

on nursing ethics perspective ten years in of working After on first research projects research about that approach to nursing we need I ethics, a thing

care generally in nursing and in health debates and is professional power. Nursing's territoriality to medicine in relation to a large is, then, position extent control determined essentially of nurses and this may have take the Issues by power. define the domain includes ethical to discontinue of power and of the concerns care Doctors - nurses

involving bioethics am still

a multidisciplinary and latterly writing not altogether sure

concerns.

decision

to a more as opposed called ethics', 'nursing care should we 'health ethics' (2). Why generalised as an area of concern is which ethics consider nursing an adequate notion of medicine? Would independent of medical be a reflection of nursing ethics not simply for that is put forward ethics? The argument general is that the occasions of nursing ethics the existence giving rise to ethical care nursing intensive of the mentally ill, reproductive technology, for but of life the difference care, prolongation and in the issues present debate the lies ethical way of the practical the nature they bring. problems as for medicine abortion, euthanasia, The the medical last word to have deemed is often profession in the guise in ethical albeit decisions, it is ultimately because legally judgement, This is a fact welfare. for the patient's sometimes in some of refuse of the to accept, debates or about so we a it the concern are often the same for

to put into practice. for that decision Doctors, a patient on a voluntary admit it basis, instance, may in the ward. is the nurse that has to 'keep' the patient a so the argument ethics goes, has, then, Nursing to an existence is separate and that from I know this argument ethics. of, medical independent it as a justification well and have made for writing ethics before about nursing (4). However, nursing to be very much I think we should ethics older, gets claim a close look at this justification and the product ethics. it allows, namely nursing too damning, to be rather Lest this paper appears must that I do think nurses I should it clear make it is the and debate the issues take ethics seriously nature its rhetoric and that I am of that enterprise take that questioning.

of clinical responsible that nurses would

seem

Who
We

is responsible
must look behind

for what?
the rhetoric if we are to

practice independent concern with ourselves

we have prevails with both contract, legal and moral of the most Some the nurse. with where nurses have have been challenged fundamentally challenges cases where from

If, however, nursing. that currently the situation has to conclude that the patient the doctor, notable on flawed a weak student

determine about

not cases moral

ethics might be it is that nursing just what to me that It seems ethics. the task of nursing is by and literature ethics the nursing large no more or bioethics a mirror of the medical than image literature. It and for tends to discuss There that the may to sustain same philosophers. be this. It could ethics and as be issues, a good the notion

doctors

grounds nurses were This with the

because

dilemmas reason of nursing than done difference texts. It

is true

making in the

of qualified staff, backing in electro-convulsive take therapy (ECT) part or refused to administer because sessions they drugs not the in the best interests of it was believed It would seem and to me that unless ECT is prescribing is not compatible of Psychiatry, complaint of decisions

position. often nurses, to refused have

a separate not so one would the nursing interplay issues

between

said is easier entity to find much expect ethics and medical between medicine's the two and ethical values as of and

perspectives nursing's Much debates being

patients. psychiatrist a way that of

a in

the is perhaps on ethical that has been of centres the

administering the code with

the College for grounds Doctors' clinical licensed clinical

the then non and co-operation. are made nature that makes training a mandate to

of practice nurse has no on

neglected. to contribution nursing the idea of doctors' around decisions Because between and of dressed the

hidden

in clinical judgement'. distribution

'professional the power nursing nature

up nature

medicine

grounds;

practitioners

psychiatrists' with

them make

is recognised this mandate decisions; by has a different nurses' The end-goal. society. training want to argue with but this state of affairs, One might as things that certain it is quite clear stand currently for and little can be gained doctors lie with powers for that ethics or, matter, care, by nursing patient at individual nurses individual taking side-swipes

come to the down discussions ethical many work and to the question of interdisciplinary to unpack need is responsible for what. We of who some and of the value examine and judgements stands that are for are embedded the and in 'clinical the for largely the most product part, with judgements. that nurses judgements', of medicine. Nurses consequences not It should their part of be have

which deal, these

decisions though,

forgotten,

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions

Kath M Melia

value

practice examination. A

judgements and of

embedded decisions. the literature

in These,

their

own too,

clinical require of all

philosophers paying when he describes his 'a philosopher's arise in and are This

attention book as

to

nursing

ethics

review

reveals so a utilitarian to a nurses

introductions become adept a deontological exists very it all. This little

to ethics

for nurses

any number can that we

approach shaped

to bioethical by nursing

issues

as they

practice'.

at recognising approach about what

or argument but there situation, in practice make of to philosophers, on data go

is very

unlike

sociologists,

possibly not do instead

because tend

stands promise largely unfulfilled. standard for ethics, justification nursing as it does on the fact that ethical leaning heavily to nursing issues in a different themselves present The of experience to get nurses into nursing issues nursing ethics

in a they come by cases them. and reflect way upon an it is too simplistic that (5) has Jennings argued to that what social scientists say is, explanation study to be. He and what that ethicists argues ought gathering expeditions, rather more particular bioethicists do have they study: perhaps define scientist might empirical experience it is not fieldwork it, nevertheless, of as the areas a social are

from the medical way profession's case is a good ethical issues, enough to get whether into ethics; they have matter. is perhaps ethics another Let covered ethics us take a closer look at the in the nursing ethics texts, by and large, tend texts new and has the literature. to mirror

substantive That medical

bioethicists

or bioethics nothing

not writing in a vacuum. However, to concentrate for philosophers rather tend labels Beneficence exception real sense everyday. to be presented with (Kantian, than the Nurses

there is a tendency on the spectacular in practice, then, of dilemmas and

disadvantage serves possibly health

in the wider nursing that most the case indistinguishable been obvious nursing emergence to write and the ethics about second and These ethics to

a literature

nursing from medical to carve focus. nurse

of producing to marginalise care debates. it is Whilst are almost texts ethics ethics out The an has texts, area resulted first there have in the on which

Utilitarianism, Justice, Rights, the possible ethics texts, with etc). These of the case-based do not in any discussions, add to the literature.

efforts can the

This as

of two main

trends.

is a concentration appropriate are avenues health

the patient's on the caring as

is a tendency advocate ethics of

A fairly
Ethical with

standard
issues for

pattern
nurses are bound invariably and inter-professional up

caring business. nursing

structural organisational, of course, factors with the question and, care The ways in which is organised and of the fessionals decisions working involved relationships both have

of power. the nature

of nursing or more from medical ethics, care ethics. and perhaps A health widely, desirably, a look through the nursing ethics literature reveals and approach to the subject standard pattern fairly matter. or to be philosophers tend The authors philosophers uniformly contain and the case. nursing a few remarks about why these generally ethics work range to present that moral issues tend in ways that differ from issues. lesser ethics some theories persons, beneficence, nurses, A typical although this ethics is not text will

nursing a convincing made as distinct ethics

the between pro a bearing on the ethical are made. that I would that the argue as it currently ethics literature stands has not case for the existence

in general. and the ethics of caring, if they are to be Advocacy to nursing, cause linked firmly could tensions with the of medicine that doctors profession by suggesting care and place don't in need of an advocate. patients

and

problematic care ethics

nursing's both for

Advocacy Let with us first

has look

adversarial at

connotations The main has difficulty adversarial is not First, can and own

position connotations. The a useful there is no

this

advocacy. is that advocacy advocacy for way

route, nursing

necessarily because be the

then, to go.

reason

sufficiently ideologies would

removed of health to make and have

to suppose that nurses from the organisation care and from nursing's

it is a nursing around the idea themselves the medical texts and There are more They by autonomy, drawing the for These detail books. texts to

nurses

of moral profession's experience in greater then and proceed to mirror medical sophistication is a good deal of case discussion; or and less devoted ethical to case-based and for describe principles respect

a patient's case as an a It might also bring nurse into conflict with his or her duty to care. Is the nurse to plead if it is not the case for a patient going in his best clinical interests? How do we balance the to care and nurse's to self the patient's duty right ideologies, advocate plead to do. determination? advocate patient's care professionals Also, to set that the the nurse rest suggests and as the up of the health

discussion. focusing,

on large, informed consent, upon Kant

mostly

and justice and Mill.

are working the system the patient's interests: this might best well be against cannot to be neutral claim in true, but nurses players the game. Nurses have of their power, by virtue and familiarity with the system, whereas knowledge in general, vulnerable. So at best the are, of the nurse-as-advocate is likely to resemble activity on the part of the nurse benevolent and paternalism patients

in his work, Jameton (6), comes Ethical closest Issues,

Practice Nursing a case to making

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions

10

The task of nursing ethics

trusting Nurses

acceptance may

on

the

uncertainty in the best

to act their attempts in It is precisely the patient. work. lack empirical that we of areas these kinds is for the most The literature part ethics-of-caring in It deals and possibly ill-founded. rather vague interests of and rather leaving reality the fact idealistic aside of most that the care. care notions It also is as of individuals, institutional rather its focus can caring and as too of be do see

to have simply which accompanies

part live

of with

the the

patient. moral

might than

one route is to develop it If nursing ethics usefully, rather be to focus upon the patient take would on to concentrate codes and professional in it but its present form at least it does have with because

The of caring ethics aspirations. does not have a lot to commend start the to focus advantage on practice of being and rather

the patient. Nurses more constantly and that

exhortations for

than are other the patient they are able to co-ordinate receives of what means at least from life have care various is like for

professionals the care

organisational unproblematic a notion general professional defined widely frequently how nursing

treats

quarters, they have This the patient. vantage in a position

the patient some view point they of for

to claim for nursing In other words activity. and well. could

that nurses are

caring

are placed some idea of then well from the

where

and

that lay people is something to It is therefore difficult make a success literature doubt on out of construct that would

care. Nurses studying

experience patients' to make the case placed

ing an ethics-of-caring or caring. either nursing are to cast if we So, ethics of caring, take? What nursing

further

what direction area of be the proper might I have that The criticism ethics? far has mainly to be more appears thus might anything be

and the advocacy ethics should nursing study made the for of fact with

vantage point knows patient William May makes bioethics,

This patient's perspective. not the be overstated: should only the patient's view. a (7), theologian the case for a study of working the ethics in of

are He that patients and families argues suffering. their have had the professionals left to cope when In other and made decision. debate their ethical words, ethical to their handled the professionals have might and family still have dilemma but the patient come to terms with somehow the live with and it here because is of interest argument and be on the patient should the focus has than on the profession. rather Nursing on the professionals' role in to focus tended His that

ethics nursing that nursing delineating than ethics too easy

to do with concerned

what with to use

nursing on doctors' territory encroaching The doctors (doctor-bashing). become the battleground, in the professional boundaries part of

recognised else. It then as ethics

as nursing all becomes a cover for

outcome. suggests practice

and for criticising to tends patient or at least an entity debates.

So what ethics?
Professional its activities

of the development
aspirations as much the can as shape

of nursing
a discipline else. We in the and can, I

perhaps in but has, decisions ethical reasons) (for very good so doing, lost sight of the patient. care ethical in debate health further Nurses might a case for placing more emphasis by making general on the patient. could part play an important Nursing in health of the care less is of health a larger element by introducing care organisation and and practice on the ought. This fits with emphasis ethics

anything

placing Jennings's bioethics

think, territory

include

arguments. that as the significance moral the arts faculties, areas medical outlet The idea in which ethics and the of

philosophers is It cuts

perhaps in university

professional not without finances hit for of

to apply or health role having of an

philosophers their discipline. care hospital ethicist ethics in

are

looking

Caring and other focus patient's

science and social that (5) suggestion to learn from each other. have much an all-important is clearly part of nursing health on care this if we work, yet professionals' the of leaving there is a danger As the out the equation. of the practice make of good the are caring to sense of and add in rather

Teaching

solely

the

one provides another. ethicist the is

experience

in the US and in, acceptance gaining be It will off taken but has not in, the UK. yet can ethicist to see how long the hospital interesting on the the of outside inter-professional stay could involves. There that teamwork wrangling are toppled a day when the doctors and replaced of dominance by position or philosopher. should ethicists Whether come from the ranks is of the health of philosophy possibly that Jennings and science a departments There partnership social both from the be their drawn ethicist

hospital about is talked

patient-experience bound closely

and

give due An ethnographic patients' traumas to our this more

it would together to both. emphasis

experiences that give rise

to approach different of to ethical if we dilemmas have

study diseases would to offer obtain

knowledge. area. It would

Sociologists also help

much

could

or from care professions for debate. is a point the between parallel (5)

benefit would suggests and a partnership nurse and benefit ethics which nursing might care. on the concept of nursing theorists working bioethics,

as nurses in practice of an idea of what regard areas We of their work. the morally problematic as: moral 'Do ask such should questions have relevance for practice?' debates philosophical in the of those working and 'What are the concerns areas of patient the rather than simply care?' taking and Rawls of Kant, Mill that the philosophers authors discussions bioethical present the are typically (these seen fit to have through) and then

works

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions

Kath M Melia

11

trying through sophers.

to make the

judgements

about

particular with Starting might

approaches the practice to other on nurses' It a

nursing practice of those philo the rather than texts. research accounts involves an project of the ethno the in debates. aim the

activities their context own

of other

health

care

professional care. of health

standing

professionals within

and with the wider

philosophy I am which moral graphic being

lead us

working currently has as its focus staff aspects of their with what the work.

Kath M Melia, B Nurs (Mane), PhD (Edin), isSenior

Lecturer the Social She health teaches and and Head Sciences Studies of Department of Nursing at Edinburgh Faculty University. research methods, ethics and the sociology illness. in

approach to discover

informal those about data

interviews, work who the moral ethical there so

of

areas think patient-care of their practice and of In addition from This would discussed care If nursing ethics to the interview participant observation include

dimension References (1) Thompson [2nd ed.] K Melia and notes

current

are field-notes care the are units. that texts. to the health ethics to me or that as it

observation was data from included the terms

in intensive areas which in ethics as nursing it seems issues the and

study so often

in abstract is to make

a contribution

part of concentrate should

either debates, a wider enterprise, on the and face care that

K M, Boyd K M. Nursing ethics. Churchill 1988. Edinburgh: Livingstone, M. ethics London: Everyday nursing 1989. Macmillan, was raised in an earlier version of this (2) This question as Melia K M. Directions and research paper published in nursing ethics. In: I Symposium internacional de etica en Y ,Conferencias enfermer?a. Pamplona, Espana: Ponencias: Servicio de publicaciones de laUniversidad 1989: 329-338. de Navarra, in trouble. Oxford: (3) Martin J P. Hospitals Blackwell, 1984. K M. Everyday (4) See reference (1): Melia nursing ethics. B. Ethics and in neonatal (5) Jennings ethnography care. In: Weisz intensive G. Social science perspectives on medical ethics. Dordrecht: Kluwer Academic 1989. Publishers, A. Nursing the ethical issues. (6) Jameton practice Cliff New 1984. Englewood Jersey: Prentice Hall, comment at a meeting at the made (7) May W. Personal 1989. Center, New York, Hastings

I E, Melia

manner very practical care. Nurses nursing come with high-tech possibilities everyday one human Nurses etc but moral

as they present in a examine the fine details of dilemmas that big new reproductive in the more involved when the care of

they choices

are also

arise

in the hands is placed of another. being a significant could make to contribution of rights, the discussion and freedom, autonomy in health-care choice if they close settings paid to the 'data' rather of less became everyday nursing concerned with and the

attention perhaps

News

and

notes

Confidentiality
Guidance been Medical Committee, issued on Confidentiality in the form of

and People

under
rather

16
than seek fear advice; many contraceptive teenagers cannot that their GP their respect owed to a to any other of regardless and give

Association, the Health

and People under 16 has a leaflet by the British the General Medical Services the Brook Authority, and Planning Association teenagers risk pregnancy

mistakenly person confidentiality; under

Education

the duty of confidentiality 16 is as great as that owed

Centres, Advisory the Royal College out It points

the Family of General that: many

Practitioners.

and any competent person, young person, seek medical advice age, can independently valid consent to medical treatment.

News

and

notes

New Medical
A new Medical at the Marmara Turkey. Contributions archives in terms be very welcome, Ethics University,

Ethics
Department Medical

Department
has been School established in Istanbul, Medical Dr Marmara G?rkey, University ?efik Ethics Cad School, Medical Dept, Tibbiye No 49, 81326 Haydarpa?a, -90 Tel: Istanbul, Turkey. (1) 336 32 05; -90 (1) 336 02 12; -90 (1) 345 34 50; fax: -90 (1) 414 47 31. Contact:

to the new

department's library and of copies of articles and books will and would be deeply appreciated.

This content downloaded from 121.54.54.59 on Tue, 9 Jul 2013 11:28:52 AM All use subject to JSTOR Terms and Conditions