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To the Editors:

I enjoyed reading Lisa Day and Patricia Benner’s article, "Ethics, Ethical Comportment, and Etiquette" (January 2002:76–79), because it truly emphasizes the importance of etiquette and ethical issues in the workplace. So many times healthcare workers get caught up in their everyday work with patients and forget the importance of etiquette and ethics.

Although etiquette is sometimes referred to as a negative aspect of healthcare, it can bring about theories of ethics. For example, Day and Benner point out the importance of informed consent. This certainly enables the patient or guardian/family of that patient to choose the best option possible for the patient’s life. It is extremely important to identify all aspects of any procedure to the patient or the guardian/family of that patient, because someone’s life is in our hands. Therefore, I agree with Day and Benner when they state that informed consent is influenced culturally and socially, because these aspects influence many decisions that are made by a patient or family member about such issues. In ethics, we are obligated to have a patient sign an informed consent, but in theory it is a practice.

In regard to respect for autonomy, I agree with Day and Benner, who emphasize that objectively we look at respect for autonomy as a part of our practice, but truly it is a foundation. Furthermore, I agree that ethics and etiquette go hand in hand with any practitioner and his or her patients. Ethics, to me, is the morals and values that are embedded in our minds from day 1, and etiquette is how we behave socially. Consequently, many practitioners use etiquette as a way to gain power and prestige, when the intent of etiquette is not that at all; I have seen this practiced in hospitals and offices in the healthcare setting.

As for the story of the organ procurement organization, this to me would be a hard and emotional job for any individual. She felt that she did the right thing by being there for the family, but, in turn, she was accused by the grandmother of just wanting organs. This definitely exhibits the way in which ethics and etiquette can turn good intentions into a bad confrontation.

I, along with many other healthcare workers, face the issues of ethics and etiquette every day at work. I work on a geriatric floor where there are many issues regarding informed consent and ethics, but you must consider cultural, social, and emotional aspects of the patient and the patient’s family and not pass judgment on a patient’s or family member’s decision regarding informed consent or other ethical issues. Etiquette toward patients and families should be taken into consideration in all healthcare practices throughout the healthcare field.

Kelli Alexander, RN
Mooresville, NC

The authors reply

Thanks for your insightful comments. We agree that etiquette can be taken over for ill or good, but that etiquette is essential for making ethical perception and comportment possible and thus cannot be separated from ethical comportment and ethics. If patients and families are treated poorly (disrespect through poor etiquette), then it will be hard for them to raise their concerns and issues with healthcare workers. If etiquette is co-opted for "marketing" relationships, then the most we can hope for is "honest" salespersons selling good products. But care of critically ill patients requires fiduciary relationships that demand more than selling products. Fiduciary concerns are required for the critically ill in order to protect patient and family vulnerabilities. This requires that healthcare professionals act in the best interests of patients and families from a stance of genuine regard and respect. So etiquette can open up safe social spaces that enable person(s) to disclose their concerns and entrust themselves to the care of others when that is necessary. On the other hand, poor etiquette, in the form of manipulative ethical comportment and diminished ethics, can seek the best ends of the institution or healthcare worker instead of attending to the persons’ needs and vulnerabilities with genuine respect for persons as ends in themselves.

Lisa Day, RN, PhD
Patricia Benner, RN, PhD

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