| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
CURRENT CONTROVERSIES IN CRITICAL CARE |
Corresponding author: Lisa Day, RN, PhD, Assistant Clinical Professor, Department of Physiological Nursing, University of California–San Francisco, Campus Box 0610, San Francisco, CA 94143 (e-mail: lisa.day{at}nursing.ucsf.edu).
What motivates us to do good work? Nurses and physicians who work to improve the health of critically ill and injured patients might answer this question differently depending on their individual circumstances and background. But is there a common understanding of what should motivate healthcare providers in critical care to do their best work for the patients and families they encounter?
Ethical theories offer different and sometimes conflicting descriptions of how people are motivated to do the good or right action. Immanuel Kant’s discussion of duty in Groundwork of the Metaphysics of Morals (1785)1 and utilitarian ideas about maximizing pleasure or happiness are 2 such conflicting theories of motive. In contrast to both Kantian duty and utilitarian theory, theories of virtue ethics describe motivation to do good work as a part of character development. In other words, being a good person by cultivating virtues will result in motivation to engage in good actions.
I would like to take up a discussion of the philosophical foundations of clinical ethics by exploring Kantian duty as well as the notion of utilitarianism and contrasting these ideas with virtues and care ethics. Then I will discuss how the notions of good that are internal to critical care nursing practice, those goods that the virtues of the practice support and are supported by, can be overlooked in favor of the procedural ethics (based in Kantian autonomy mixed with utilitarian ideas) that is supported by the acute care institution. I choose nursing as my example of a practice rather than medicine, physical therapy, social work, or any number of other healthcare practices that exist in acute care because nursing is the practice with which I am most familiar.
Kantian Duty and Autonomy
In Kant’s moral philosophy, which to a great extent forms the background to clinical ethics, a good act is one that arises from a motive of duty and is tied to pure rationality. For Kant, the only thing that is purely and unequivocally good is a good will. Acting from duty arises from a good will and therefore any actions produced will be good and right actions. Because duty is completely tied to rational thought, it provides a motive for good action in a reliable and predictable way. When acting from duty the agent is not concerned with his or her own desires, inclinations, or personal happiness, and therefore produces good actions that are neither influenced by external demands nor predicated on the outcomes they produce.
What motivates one to act from duty is the internal logic of the proposed action, or, in Kantian terms, the maxim. This is evident in the first form of Kant’s categorical imperative, a binding rule about action: "Act only on that maxim through which you can at the same time will that it should become a universal law."1(p88) The categorical imperative defines good actions as those that can be rationally willed to become universal law for all rational agents.
Kant’s most famous example of a violation of the categorical imperative is that of the lying promise, which can be illustrated in the following example: a nurse is caring for a patient who has been severely brain injured in a motor vehicle crash and is unconscious after surgery to evacuate a subdural hematoma. The nurse is trying to comfort the patient’s distraught husband, Mr K, as he prepares to leave the critical care unit for the night. It is very important that Mr K spend the night at home because, aside from his own exhaustion, the couple has 2 young children who have seen neither parent in several days. Earlier that day, Mr K had seen the attending neurosurgeon in charge of his wife’s treatment handle her roughly. He then had a heated argument with the surgeon, who informed Mr K that, as the doctor in charge of his wife’s treatment, she had every right to examine her patient and reminded Mr K that he had signed the consent for surgery as well as the conditions of admission for the hospital. Mr K wants to be there the next time any physician examines his wife; the only way he will agree to leave his wife’s bedside is if the nurse promises that while he is away no physician will be allowed to examine his wife. The nurse contemplates whether to make this promise even though she knows that the attending neurosurgeon will be in later that night and will examine the patient.
To make this promise knowing she will not keep it would violate the categorical imperative because a person of sound reason cannot will this act to be a universal law. This is true for Kant not because of the problems it would create for the world if everyone went around making false promises; that would be a pragmatic influence on action that Kant is not concerned about. On the contrary, Kant is focused on the reasoning of rational individuals. Making a lying promise is unacceptable because willing it to be a universal law would mean that everyone who promises will be lying about the promise. This creates a conflict with the very idea of promising and thus makes a promise—at least as we understand and define it—impossible. Therefore, the maxim of the lying promise creates a logical conflict in its formulation; a rational person cannot accept it as a universal law.
When thinking about Kant’s ideas of moral motivation, one must appreciate the role of reasoning. The nurse who makes a lying promise to Mr K might justify her actions by saying that it was the only way to get him to go home, which he needed to do for his own health and for the health of his children. This provides incentive for the nurse to act as she did, but it should not be mistaken for a reason.2 Neither should it be mistaken for a moral motive. In Kant’s formulation, a good act has a reason that is derived from adherence to the categorical imperative and that motivates the rational person to act from duty and possibly against personal inclination and desire. Although actions may have more than one motive, only the presence of an overriding motive of duty makes an act moral in the Kantian sense.3
Kant’s contribution to clinical ethics lies in his emphasis on individual autonomy and rights. People are rational agents and, as such, are to be treated never as mere means but always as ends in themselves. This second formulation of the categorical imperative—"act in such a way that you always treat humanity ... never simply as a means, but always at the same time as an end"1(p96)—forms the basis for individual autonomy by establishing each individual as the setter of her or his own ends. However, at the same time, Kant grounds his notion of autonomy in his faith that rational agents will act rationally; that is, in setting her or his own ends, a rational agent will act according to duty and in keeping with the first formulation of the categorical imperative. Thus an autonomous individual will act only on maxims she or he can at the same time will to be universal law—and that could mean acting against one’s own desires and doing things that cause pain to oneself or others.
The idea of human beings as ends in themselves, never to be treated as mere means, is firmly established in clinical bioethics; in fact, it shows up as the prioritization of autonomy and is enacted in part by obtaining informed consent. Although Beauchamp and Childress4 would deny that this idea is any more important than the other principles they discuss, their text on principle-based ethics, Principles of Biomedical Ethics, devotes a chapter to autonomy, most of which is spent discussing aspects of informed consent. Despite the equal space these authors devote to the other principles—nonmaleficence, beneficence, and justice—many clinicians consider autonomy to be the "trump" principle that overrides all other considerations. Obtaining informed consent is a way to ensure that people are treated as ends and that the proposed action (eg, treatment, diagnostic procedure, enrolling as a research subject) is compatible with an end the patient has set for her- or himself.
Although the notion of individual autonomy taken up in clinical ethics is Kantian in some respects, it is also in some ways at odds with Kant’s philosophy. Most often clinicians think of respect for autonomy as doing what the patient expressly desires. The autonomy that overrides all other considerations in clinical ethics is a matter of identifying the patient’s individual preferences and acting in keeping these preferences. But Kant’s idea of autonomy does not include any consideration of individual preferences or desires; what one desires can get in the way of what duty demands and cause one to act irrationally, thereby curtailing rational freedom. In seeking informed consent, questions of competence and decision-making capacity are entertained but questions of rationality in the Kantian sense are not; clinicians ask patients what they want but do not typically ask whether the patient’s proposed maxim can be willed to be a universal law.
The prioritizing of individual preference and desire in clinical ethics goes against a pure Kantian notion of autonomy and freedom and is more consistent with some aspects of utilitarian theories of ethics that demand the agent to act in whatever way produces an outcome that maximizes the good. For humans and other sentient beings, the good outcome is one that maximizes pleasure and minimizes pain. The individual agent who is weighing 2 possible actions to decide which is the right thing to do must ask which act will produce the most happiness or pleasure. For example, weighing the benefits and risks is one way an autonomous individual might go about deciding whether to consent to a medical procedure.
But for Utilitarian theorists such as Jeremy Bentham5 and John Stuart Mill,6 who were interested in the political landscape and larger issues of social justice, the outcome sought was that of the most average pleasure or happiness in an entire population. Clinicians, by contrast, take up the utilitarian focus on outcome and apply it to the individual patient and family. In this way clinical ethics as it is practiced in acute care institutions sets a goal of maximizing happiness for individuals who must define happiness in their own terms and are expected to consent to or decline interventions based on that definition. This blending of Kantian ethics—with its focus on the individual—with utilitarian theories, in which the right action is the one that produces the best outcome for a community, is typical of the procedural ethics relied on in an acute care institution when clinicians confront ethical dilemmas or quandaries.
Virtue, Care, and Socially Embedded Practice
Two moral theories that are offered as alternatives to Kantian and utilitarian theories are virtue and care-based ethics. Virtues and care have been proposed as more descriptive of medical and nursing practice and as having much in common with one another.7,8 On first glance, virtue theory also has some similarities with Kantian duty as the basis for moral motivation to do good work. For Kant, good work requires one to cultivate rationality and to evaluate each act according to how it satisfies the categorical imperative. The virtues must be similarly cultivated and a good action is one that is motivated by one or more of the virtues that have been internalized. But acting out of virtue is a very different idea from acting out of duty as Kant conceives it.
The best account of how the virtues might work in modern society is offered by Alasdair MacIntyre, who describes the virtues as socially embedded rather than individual and as developed in relation to a practice that has a social history and goods internal to it.9 In his discussion of the background against which the virtues are understood, MacIntyre9(p187) defines a practice as
any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended.
Of key importance for unpacking this definition of practice and relating it to the virtues important to nursing are the presence of internal goods and the social and historical nature of practice. MacIntyre also points out that practices are most often associated with institutions that provide some structure in which the practice is able to flourish. It’s an apt description of the relationship between critical care nursing practice and the acute care hospital.
Goods internal to a practice are internal in 2 senses: (1) the goods can only be described in terms of the practice, and (2) they can only be recognized by engaging in the practice and having the associated experiences. Recognizing the goods internal to a practice requires an understanding of the history of the practice as well as concrete experiences of engaging in the work.
Unlike Kantian duty and the categorical imperative, however, internal goods cannot be abstracted from the particular experience and made into eternal rules. Goods internal to a practice are best described by examples from the practice and can only be identified and judged by those who have had relevant experiences within the practice. In the example of the nurse who is contemplating lying to her patient’s husband, the Kantian analysis required that the nurse disengage from her experience and take up a purely rational thought project to form a rule abstracted from the experience with this particular patient and family that can be applied in all situations that involve a false promise. In contrast to this, a description of the nurse’s experience in the situation with this particular family is what will expose the goods that are at stake for her.
Another important distinction between Kantian duty and the virtues that arise from the goods internal to a practice is that a practice is a socially embedded activity that takes on a narrative form, with a past, present, and future. Kant would expect the rational person to be motivated to do the good action by engaging in pure, atemporal rationality uninfluenced by current circumstances; one’s own preferences, needs, and desires; or the preferences, needs, and desires of others. Engaging in a practice is a social activity that stands on and grows from the history of the practice. Rather than relying on one’s own rational mind, alone in abstract contemplation, understanding and committing to the goods internal to critical care nursing requires one to take up the practice and engage with others who are involved in the practice and to contemplate the history on which current practice is based.
In committing to critical care nursing practice, the nurse’s actions are understood as part of a narrative history. In the example of the nurse who is considering lying to her patient’s husband, the possibility of this action becomes intelligible only within a larger, contextualized narrative in which "[w]e place the agent’s intentions ... in causal and temporal order with reference to their role in his or her history."9(p208) It is possible to characterize the nurse’s action in different ways, all of which might be accurate in describing her motivation for lying:
All of these motivations are embedded in the historical context of the particular critical care unit and in the situation of caring for this particular family. When we engage with the story of Mr K, his wife, and the nurses, we fill in the meaning that is left out of the disengaged, Kantian rationalist account and expose the truly problematic nature of lying in this situation. By lying, the nurse will be able to accomplish most of her goals but will risk undermining her intent to help Mr K feel safe, which is the intent that reflects the nurse’s responsiveness to the vulnerable other and is the priority of nursing practice. The intent to help Mr K feel safe is the priority not because it is a more rational or reasonable motive, but because it expresses a good internal to nursing practice. It is this motive that is visible to the nurse who has cultivated the virtues within her or his practice.
The connection between practice and virtues is a dialectical rather than a means-end connection. Cultivating certain virtues enables the nurse to achieve the internal goods of his or her practice; realizing internal goods then contributes to reinforcing the virtues. This description differs from the classical Greek account of the virtues as enduring traits of inner character by shifting the emphasis toward engagement with a practice that, in the case of nursing, involves the nurse in relationships. As Benner8 has pointed out, goods internal to nursing practice are focused on the other—the patient and family—rather than on the nurse’s inner character. Even so, cultivating relational virtues such as openness and responsiveness will allow the nurse to realize the goods internal to the caring practice of nursing that include attending to and prioritizing the needs of the patient as those needs become apparent.8
The Institution and Practice of Critical Care Nursing
Perhaps the most important difference between virtue and care ethics and Kantian and utilitarian ethics is that whereas Kant and the Utilitarian philosophers ask, "What should I do?," critical care nurses engaged in virtue and care ethics ask, "What kind of nurse should I be?" This shift in emphasis from knowing to being is important to an understanding of how the procedural ethics of the acute care institution might conflict with the substantive ethics of nursing practice.
Clinical ethics as it is taken up in acute care hospitals in the United States is rooted in a Western philosophical tradition that owes a great deal to Kant and to utilitarianism. Although nurses may understand their practice in terms of care, virtues, and internal goods, and may relate best to narrative accounts that include descriptions of emotion and conflict, the institutions in which they work operate in a world of objectivity and rationality described in terms of duty and rules. Rules that protect rights such as patients’ self-determination are codified in hospital policy and are meant to apply in all circumstances.
The patient’s husband in our example does not want to leave his wife alone because he is afraid of what she might be subjected to as part of a neurological exam. Kantian duty requires that the nurse not make a promise to Mr K that she does not intend to keep. Submitting to the attending neurosurgeon’s examination is part of what Mr K consented to for his wife when she was admitted to the acute care hospital; through use of a surrogate acting on her behalf, the patient has had her autonomy protected.
Respect for individual autonomy and the right to determine one’s own ends is essential in ethical health-care practice. But, as others10–13 have pointed out, rights and individualist notions of autonomy are not sufficient to sustain a caring and empathetic practice. Being attentive and responsive to Mr K’s needs requires that the nurse take time to explore his fears and try to help repair his relationship with the neurosurgeon. Whether the nurse takes up this work will depend in part on Mr K’s personality and communication skills, the nurse’s skill at relational work of this kind, and how much time the nurse feels she can devote to her patient’s husband. So whereas the institution’s policies ensure that the patient’s right to autonomous choice is respected, Mr K and his wife may or may not receive the care they need.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
None reported.
This article has been cited by other articles:
|
|
 |
|
  A. Jennings and L. Day Exploration of Power Imbalances and Communication Are Key Am. J. Crit. Care., September 1, 2007; 16(5): 430 - 431. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
