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CURRENT CONTROVERSIES IN CRITICAL CARE |
Biomedical ethics applied to nursing and medicine has been concerned primarily with 8 interrelated areas: 1) clinical competence, judgment, and comportment of practitioners; 2) fair allocation of scarce resources; 3) protection of human subjects; 4) ethical assessment of medical technologies; 5) ensuring patient rights including autonomy and informed consent; 6) beneficent practice; 7) nonmaleficence; and 8) social policy related to healthcare. These bold ethical agendas are still being worked out and will continue to be central to the ethics of healthcare.
In the now classic biomedical textbook on a principle-based approach to bioethics, Beauchamp and Childress2 present 4 major ethical principles (autonomy, justice, beneficence, and nonmaleficence) that can be applied to reach decisions in cases of ethical conflict and dilemmas. Patient autonomy and informed consent as overt ethical reforms to paternalism exerted a strong moral influence in medicine and nursing. The focus on autonomy, justice, and individual rights helps institutionalize principles of justice in the decision-making structures and processes of public institutions in which the care and meeting of strangers take place.3 As O’Neill3f points out, inequalities and vulnerability are gathered in public caring institutions; therefore, firm structures and policies that ensure justice are minimally required to prevent neglect and abuse of those who cannot adequately demand or defend their rights. Beneficence, nonmalfeasance, and a fiduciary relationship are required when rights’ bearers cannot understand or demand their rights. Justice alone is not enough to ensure the care of those whose acute illness, youth, or advanced age renders them unable to fend for themselves. The ethical landscape of healthcare requires a vision of one’s basic relatedness to others and notions of a good life in relation to the human condition. For example, in situations of inequality and vulnerability, mercy and generosity will also be required to ensure that rights’ bearers who cannot demand their rights will have their needs met and will be protected and nurtured. Sandel4 points out that justice is remedial—it corrects or repudiates injustice. Justice and procedural ethics lodged in institutional policies and processes are necessary but not sufficient. Moral imagination and solidarity with one’s fellow human beings are required to avoid constant infractions of justice.
Biomedical ethics has provided an external voice and disciplined thinking about patients’ rights, and healthcare professionals’ duties and obligations to patients. The need for an external voice aligned with public interests continues to be crucial in the current climate of market models of healthcare delivery5–8 and as evolving technologies create new moral questions and dilemmas. Healthcare professionals must not be left in isolation to think about central questions regarding rights to treatment, the right to die, informed consent, new biological possibilities in reproduction and fertility, new genetic testing and therapies, and continued threats to equity in healthcare access.
A current challenge for bioethics lies in strengthening and linking their external critique with the moral sources and notions of good within the practice of professionals. This is a challenge to create better public language and understanding of the narrative and scientific traditions, and notions of good that are central to public caring practices. We have much to learn about the ethical wisdom, and ethical breakdowns embedded in the daily experiential learning about being a good nurse, physician, or social worker.9,10 Practices are socially embedded and are lodged in narratives and traditions.11 Therefore, they cannot be completely objectified or formalized because of their complex social, practical, local, and historical bases. Being a good practitioner requires action and reasoning in transition with particular persons in particular situations.12 Being in-relationship to particular persons or situations requires engagement and experiential learning, but as this particular relationship is lodged in a social tradition of schooling, science, and education, those engaging in a practice can recognize strong instances of excellent or poor practice.13–15 An experiential component to learning skillful ethical comportment is central to the nursing and medical practice but cannot be encompassed in the science of the practice. Here the humanities’ side of ethics and examples of excellent practice can provide a continuing renewal of moral imagination within the practice. An amended translation of Gadamer by Dunne16,17 clarifies distinctions between experiential learning and science:
Experience [Erfahrung] itself can never be science [wissenschaft]. It is in absolute antithesis to knowledge [Wissen] and the kind of instruction that follows from general theoretical or technical knowledge. The truth of experience always contains an orientation towards new experience. That is why a person who is called ‘experienced’ has not only become such through experiences but is also open to new experiences. . . [and] is particularly well-equipped to have new experiences and to learn from them. The dialectic of experience has its own fulfillment not in definitive knowledge, but in that openness to experience that is encouraged by experience itself.16,17
Both the articulation of exemplary practice and the experiential learning of professionals have received less attention from ethicists and philosophers, though there is a growing interest in this narrative approach to ethics.10,18–21 Moral development and experiential learning within excellent practice has its beginning in the work of Aristotle, but has recently been revived as a moral source in healthcare ethics.15,22,23 Charles Taylor’s12,24–27 philosophical writings on moral sources and his work on public and private life offer ways to broaden the current bioethical discourse. Taylor24 argues that people take a stand on life through making strong evaluations—some choices are strong, not simple because they are linked with the person’s sense of who they are and what matters to them. Strong evaluations, as opposed to simple consumer choices, require that a person make qualitative distinctions in ethical comportment and reasoning.24 In nursing and medical practice, ethical (notions of the good and relationship with the other) and clinical discernment are linked. Distinctions between beneficence and maleficence in helping relationships are qualitative distinctions and are strong evaluations.14,15,28
Aristotle29 was the first to see the importance of the development of character and moral sensitivities within a practice over time. Joseph Dunne17 notes that having mastered the notion of techne handed down by Plato:
[Aristotle] nonetheless stopped short of according to it an unlimited jurisdiction in human affairs. Besides poiesis, the activity of producing outcomes, he recognized another type of activity, praxis, which is the conduct in public space with others in which a person, without ulterior purpose and with a view to no object detachable from himself, acts in such a way as to realize excellences that he has come to appreciate in his community as constitutive of a worthwhile way of life. . . . Praxis required for its regulation a kind of knowledge that was more personal and experiential, more supple and less formulable, than the knowledge conferred by techne. This practical knowledge (ie, knowledge fitted to praxis) Aristotle called phronesis, and in his analysis of it, in which he distinguished it explicitly from techne, he bequeathed to the tradition a way of viewing the regulation of practice as something nontechnical but not, however, nonrational.17
Learning to be a good nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning.30 Six aspects of skillful ethical comportment and clinical judgment are highlighted as central to becoming an excellent practitioner: 1) linking clinical and ethical reasoning; 2) thinking in action and reasoning in transition; 3) perceptual acuity and the skill of involvement; 4) skilled know-how; 5) response-based practice; and 6) agency.6,11 In this view, ethical and clinical reasoning cannot be separated because the vision of what is good, bad, or harmful dictates sound clinical judgments. The moral sense of what is good to be and do in a situation guides problem identification, therapies, and evaluation of care.6,10,11,31 Nursing is a relatively new discipline and a public caring practice, so many of the internal notions of good in nursing are unarticulated or have difficulty being recognized as legitimate public discourse.32
Taking up a practice requires that the practitioner acquires the habits, dispositions, skills, and emotional responses of excellent practitioners. This requires experiential learning, which as Gadamer16 points out requires having one’s preconceptions and expectations turned around, so that understanding, dispositions, and knowledge are changed. The possibilities of moral agency are dependent upon one’s vision of a good life, experiential wisdom, skilled know-how, relationship, openness, and responsiveness. In our research, we found that moral agency, ie, the sense of one’s possible impact and influence on the situation for the beginner consisted in achieving preset goals, accomplishing tasks, and being respectful and considerate.11 At the proficient and expert levels of practice, moral agency was more attuned to particular concerns in clinical situations and nurse-patient relationships. One’s visions of what is possible and capacities to act are based on experiential learning. This stance offers a perspective on the differences between the Kohlberg33 and Gilligan34 visions of moral maturity and distinctions between a practice-based and a principle-based approach to bioethics:
If one thinks of morality exclusively in terms of judgments, which are generated by principles, ethics looks like a form of practical reason, and the ability to stand back from the situation so as to insure reciprocity and universality becomes a sign of maturity. But if being good means being able to learn from experience and use what one has learned so as to respond more appropriately to the demands of others in the concrete situation, the highest form of ethical comportment consists in being able to stay involved and to refine one’s intuitions. . . . Thus when he measures Gilligan’s 2 types of morality—her 2 voices—against a phenomenology of expertise, the traditional western and male belief in the maturity and superiority of critical detachment is reversed. The highest form of ethical comportment is seen to consist in being able to stay involved and to refine one’s intuitions. If, in the name of a cognitivist account of development, one puts ethics and morality on one single developmental scale, the claims of justice, in which one needs to judge that 2 situations are equivalent so as to be able to apply one’s universal principles, looks like regression to a competent understanding of the ethical domain, while the caring response to the unique situation stands out as practical wisdom. If so, the phenomenology of skill and expertise would not be just an academic corrective to Husserl, Piaget, and Habermas. It would be a step toward righting a wrong done to involvement, intuition, and care that traditional philosophy, by passing over skillful coping, has maintained for 2500 years.30
Thinking in action and reasoning in transition refer to practical reasoning or phronesis that takes into account changes in the practitioner’s understanding of the clinical situation and transitions in the condition of the patient or family.6,35 This form of reasoning takes into account changes in perception and directional changes in the patient’s condition. Charles Taylor12 has contrasted this form of reasoning (which approximates a moving picture) with reasoning that compares 2 points in time by spelling out the situation, and the formal criteria for judging the situation into absolute yes and no decisions—the model of rational, technical, or scientific reasoning. As Taylor points out,12,25 moving from a confused understanding to a clearer understanding reduces error and clarifies limits and possibility in the situation. Keeping track of past, changing, and current understandings is the form of practical reasoning or phronesis that engages nurses in their practice. Phronesis requires the moral arts of attentiveness and engagement with the other. Threats to this practice are fragmented caregiving episodes, having to delegate too many tasks so that one loses track of the patient’s changing condition, and lack of time for developing relationships. This form of thinking requires more than applying knowledge or subsuming things under categories. As Logstrup36 points out, "Subsumption is not cognition but an application in which we test whether our cognition was correct." This insight can be extended to bioethics. Justifying ethical decisions based upon ethical principles in bioethics such as autonomy, justice, beneficence, and nonmalfeasance does not ensure that the practitioner will notice when these principles are at stake in actual patient care or will be able to develop the relationships that will open possibilities and thinking in action. Ethical principles can enhance accountability and allow for grievance and justification, but the moral agent must breathe life into these principles in action and in fiduciary caring relationships.37 The nurse learns how to be appropriately moved by meeting the other and by visions of being a good nurse in the particular situation.
Everyday ethical and clinical comportment are guided, not so much by quandary and extreme cases that fall outside the boundaries of good practice, but by usual understandings about worthy competing goods in particular clinical encounters. For example, the clinician must make qualitative distinctions between care and control, comfort and suffering, and these distinctions depend on context and relationship.14 Therefore qualitative distinctions cannot be made through objectification or rational calculation. Emotional attunement creates the possibility of rational action, despite the fact that emotions can also be the seat of irrational actions. Emotional responses can act as a moral compass in responding to the other and in guiding one’s sense of the situation. Emotions, viewed this way, are neither empty of cognitive or moral content or necessarily disruptive and faulty.
The expert nurse can identify problems because of perspectives from past clinical situations. Consequently, expert clinicians do not just engage in knowledge utilization; they develop clinical knowledge. A practice in this view is not merely carrying out an interiorized theory; it is a dynamic dialogue in which new understandings of theories may be created. The expert is frequently called upon in novel, puzzling, or breakdown situations.
From a contractual vision of the meeting of autonomous strangers, we do not think of ourselves as being constituted by others, and tend to think of the moral self as that which is owned by the self and freely chosen. Care, connectedness, responsiveness, and interdependence are signs of a moral lapse and are sources of embarrassment for the strictly atomistic vision of the individual. For the autonomous choice maker, care and caring practices are yet another set of choices until the position of caring or needing care intrude, because care always implies situated or bounded choice.25 In intimate spheres, loving a child or parent precludes freely choosing to stop caring about the parent or child, though one may physically separate from the other. In less intimate spheres, when one is vulnerable or incapacitated, choices about being cared for and receptivity to care are constrained. Care, whether public or private, is bound up with the human condition.
Embodied, skilled knowledge is central to thinking in action and excellent ethical comportment on the part of the practitioner.6 Learning how to skillfully respond in the moment of actual concrete situations lies at the heart of becoming a wise, effective nurse. An empathic response is blocked if the nurse does not know how to actively listen, or to design the best monitoring and dosing of pain medication and comfort measures. Taylor27 and Logstrup38 note that we are in danger of reducing ethical discourse to decisional ethics, so that action, relationship, skilled know-how, and ways of being in the situation are overlooked, while adjudicating right decisions according to well-formulated ethical principles become the preoccupation of ethicists.
Drawing on Taylor27 and Murdoch,39 emotion in the form of loving the good, moves us to act. Charles Taylor makes the point that our sense of moral obligation is dependent on the broader and more fundamental sense of what it is good to be:
But ethics involves more than what we are obligated to do. It also involves what it is good to be. This is clear when we think of other considerations than those arising from our obligations to others, questions of the good life and human fulfillment. But this other dimension is there even when we are talking about our obligations to others. The sense that such and such is an action we are obligated by justice to perform cannot be separated from a sense that being just is a good way to be. If we had the first without any hint of the second, we would be dealing with a compulsion, like the neurotic necessity to wash one’s hands or to remove stones from the road. A moral obligation comes across as moral because it is part of a broader sense which includes the goodness, perhaps the nobility or admirability, of being someone who lives up to it. . . .If we give the full range of ethical meanings their due, we can see that the fullness of ethical life involves not just doing, but also being; and not just these 2 but also loving (which is short-hand here for being moved by, being inspired by) what is constitutively good. It is a drastic reduction to think that we can capture the moral by focusing only on obligated action, as though it were of no ethical moment what you are and what you love. These are the essence of the ethical life.27
Notions of good lodged in caring practices cannot be guaranteed, but they can be nurtured by telling stories of good practice and by creating environments that support and encourage caring practices between healthcare practitioners and patients. Rights are essential and remedial, but they are not the only source nor the end of ethical concerns. They require a strong sense of the good that inspires and legitimizes their moral impetus.
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REFERENCES
Benner P, Wrubel J. The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, Calif: Addison-Wesley; 1989.
Benner P. A dialogue between virtue ethics and care ethics. In: Thomasma DC, ed. The Influence of Edmund D. Pellegrino’s Philosophy of Medicine. Boston, Mass: Kluwer Academic Publishers; 1997:47–61.
Davis A, Aroskar MA. Ethical Dilemmas and Nursing Practice. New York, NY: Appleton-Century Crofts; 1991.
Murdoch I. Metaphysics As a Guide to Morals. New York, NY: Allen Lane-The Penguin Press; 1992.
Pellegrino ED, Thomasma DC. For the Patient’s Good: Toward the Restoration of Beneficence in Health Care. New York, NY: Oxford University Press; 1988.
Thomasma DC, ed. The Influence of Edmund D. Pellegrino’s Philosophy of Medicine. Boston, Mass: Kluwer Academic Publishers; 1997.
Vetleson AJ. Perception, Empathy and Judgment: An Inquiry Into the Preconditions of Moral Performance. University Park, Penn: Pennsylvania State University; 1994.
Yarling RR, McElmurry BJ. The moral foundations of nursing. Adv Nurs Sci. 1986;8:63–73.[Medline]
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