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The recent Current Controversies article¹ clearly identifies key aspects of Kantian ethics. I agree that Kantian ethics do not enable the patient or provider to make sound ethical decisions in every situation.

However, upon reading Day’s narrative, I was particularly disturbed by the action of the surgeon and support the valid concerns raised by the patient’s husband. My suggestion to nurses involved in this situation is 2-fold:

First, improve communication among all members including the physician and family. Compassionate and authentic communication promotes ethical decision making by building trust and respect for each participant in the process. An atmosphere of trust and respect improves the decision-making process and the decision itself.

Second, the power imbalance inherent in this narrative must be explored. Sherwin’s account on relational autonomy² enables the nurse to assist the patient’s husband to advocate for his wife. I believe that using a relational autonomy approach in exploring this situation would be more advantageous than using traditional ethical theories.

Consent for surgery does not extend to the rough treatment of patients. The surgeon’s behavior is unacceptable and should not be tolerated by the nurse, patient, or substitute decision maker. Students should be encouraged to explore the inherent power imbalances in the workplace, thereby improving dialogue among all team members and addressing power imbalances inherent in organizations, consequently improving patient care.

Anita Jennings, MN
Toronto, Canada

REFERENCES

1. Day L. Foundations of clinical ethics: disengaged rationalism and internal goods. Am J Crit Care. 2007;16:179–183.[Free Full Text]
2. Sherwin S. A relational approach to autonomy in health care. In: Boetzkes E, Waluchow W, eds. Readings in Health Care Ethics. Ontario, Canada: Broadview Press; 2000:69–87.

Thanks for your letter and for confirming that I got it right about Kant. How those involved in the bioethics conversation take up aspects of Kant or the Utilitarians, among other theories of philosophical ethics, varies widely. What I was trying to bring out were the shortcomings of a pure Kantian or utilitarian focus within a relational practice.

With respect to the example I offered of the nurse considering making a lying promise to the patient’s husband, I completely agree that improving the communication between all involved ought to be the focus of further interactions. It is not adequate for the nurse simply to uphold the Kantian categorical imperative.

Although I agree with your point that students (and nurses and physicians) should explore power relationships in practice, I think you assume too much in your interpretation of the power imbalance inherent in the story. The brief information provided in the scenario does not warrant your conclusion that the patient’s husband is taking an advocacy stance rather than, for example, responding from fatigue or fear. Clearly the surgeon and nurse are in a position to better care for this family by building rather than undermining a trust relationship, which will require more open communication.

Lisa Day, RN, PhD
University of California San Francisco, California

This Article Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jennings, A. Articles by Day, L. Search for Related Content PubMed PubMed Citation Articles by Jennings, A. Articles by Day, L.