In recent years, most of the world’s people have celebrated their diversity: different races and languages, religions and cultures, and social mores. These differences are what make life infinitely interesting. Nonetheless, what people value most in life is remarkably similar. People love their children, seek good friends, need enough food and shelter, rejoice in work well done, and expect health enough to live fully until they die.
When these values are threatened, people become vulnerable—all the more so if they are unable to reduce the threat. Disease, or its threat, wounds what is rarely articulated as a human value—perhaps because it is the substratum upon which all else is built—quite literally a person’s relationship to self, others and the world. When one is ill, one cannot command one’s body to do what one wants it to do. Nor can one determine what is wrong or what to do about it. Thus one is forced to go to another person, to place oneself before this person and to ask for help. So it was, and so it still is…although computers are starting to punch a few holes in our “omniscience!”
Codes of Ethics came into being to protect the vulnerable from the powerful, the unwary from the unscrupulous. The very word “profession” was derived from the early practitioners’ public promise of altruism and master craftsmanship—which today are often codified in our Practice Acts. Yet, now as then, the total situation for patients includes not only their diagnosis and treatment, but also whether or not someone will stand by them through the course of their illness or death.
However, then more than now, practitioners could do little to alter this course; thus the early codes stressed fidelity to principles. Emphasis was on altruism. As knowledge grew and skills proliferated, particularly in the latter half of the 20th century, the practitioner’s ability to alter the course of disease shifted the ethical emphasis from fidelity to outcomes. Emphasis was on the craftsmanship. And the questions became: does the patient want his life altered? If so, to what extent, and who decides? The ancient moral dictum was to choose life. The modern moral dilemma is under all circumstances? And so the responsibility for such decisions rightfully belongs to patients.
Now, the emerging trend is to cede moral authority—and with it, responsibility—to patients and families (what ought to be done), while scientific authority (what can be done) remains with the professional. This shift is far too simplistic, and simplistically addressed. The ancient authoritarian ethos gave all power to determine and decide to the professional: the patient’s only (rather thin) protection being the professed altruism of the professional. However, the moral hegemony ceded to patients today leads to an ethos of moral detachment in which the professional is seen as an instrument of the patient/family’s—or even of society’s—will. So, in my recent illness, a physician told me I could go to the hospital if I wanted. And my nurse brought me medicines and said, “You can take these if you want.” Please! There is a difference—and a very big one—between unbridled paternalism and a detached “do whatever you want.”
No longer a moral agent, the professional—and the power of the profession—becomes a value-neutral tool used to achieve the ends of others. No longer an altruistic itinerant, the professional is educated, supported, protected and paid by the community. No longer morally autonomous, the professional’s choices are circumscribed by law and often determined by those whose values he may not share, and whose motives he may not know. No longer a compassionate caregiver, the professional becomes merely a powerful instrument to be put to use, or not, at the whim of others. This also is wrong! Today’s professional codes of ethics seek to balance moral authority and responsibility as both the lay and professional publics come to grips with the separation of what ought to be done from what can be done. We are partners working together and neither should dominate.
And this has everything to do with everyday practice for every one of us. Ethics has everything to do with the everyday treatment of human beings. Real ethical challenges hit you where you live. Do you maintain your competence so that the care you give is at least safe? Are your decisions based on knowledge or habit? Are you kind? Are you safe? These, and so many more very common questions are not only practical but also ethical in nature. And then, when you add the issues that arise in everyday practice, things really get interesting. My sincere hope is that we can have a lively, interactive sharing about many things—using standards of practice and ethical codes as appropriate!
Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.
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