Ethical issues

Introduction

Perceptions of ethics are as varied as the mores that inform individual behaviour. Some people see ethics as an esoteric abstraction that belongs firmly in the ivory towers of academe; others see it as an ethereal subject that parliamentarians manipulate in matters of political controversy. There are elements of truth in both these perspectives. Ethics is, however, much more than this. Nurses and healthcare professionals are involved in decision-making every day and these decisions may have an ethical component to them. The practice of health care requires not only scientific and practical knowledge, but also the ability to make judgements regarding a course of action or plan of care. The ability to make these judgements requires reasoning skills from differing approaches.

Unlike many words, the nature and essence of ethics cannot be succinctly reflected in a single definition. Taking this further, Sparkes (1992) questioned the usefulness of dictionaries and argued that the best which can be offered for ethics is a semantic interpretation. This is given as ‘the philosophical study of moral conduct and reasoning’. More simply put, ethics is that branch of philosophy that deals with matters of right and wrong. Knowledge of ethical principles may provide a framework for reasoned thought but cannot provide universal answers.

Sparkes’ interpretation gives direction and focus to the essential themes of ethics. In essence, it is concerned with the way in which reason can clarify situations that have a moral dimension. This last point gives a prima facie rationale for placing ethics at the centre of the nursing equation, since the focus of that profession is steeped with issues that demand ethical enquiry and a moral response. Mirroring the vibrancy ethical analysis can offer nursing, Tschudin (1993) asserts that ‘ethics is not only at the heart of nursing; it is the heart of nursing. Ethics is about what is right and good. Nursing and caring are synonymous, and the way in which care is carried out is ethically decisive. How a patient is addressed, cared for and treated must be right not only by ordinary standards of care, but also by ethical principles’. Jones (2000) describes ethics as ‘the application of the processes and theories of moral philosophy to a real situation’ and states that ‘ethics is concerned with the basic principles and concepts that guide human beings in thought and action and which underline their values’.

Unlike many of the sciences, ethics is not a precise discipline. While it seeks to find answers, on one level, to questions such as ‘What is right? What is good?’ and at another level to resolve practical dilemmas such as whether to carry out a particular treatment or not, it can seldom provide a definitive answer. What it seeks to do is provide a framework, a means of formulating answers to questions/problems/dilemmas and so guide actions. However, as will be seen, in many situations different people might arrive at differing answers and so take different actions which are neither necessarily correct nor incorrect. The important thing is to justify the decisions and actions on the basis of sound ethical reasoning.

The purpose of this chapter is to use philosophical reasoning to examine some areas of moral concern that frequently confront practitioners not only in emergency departments but in all emergency care settings. These areas will provide a philosophical adjunct to the legal issues that are covered in Chapter 39, e.g., a duty of care and consent. The reason for this is to conduct an ethical examination of concepts central to healthcare law in this country. The lines between law and ethics have become blurred over the years and to consider ethics in isolation could potentially distort practice. In an increasing litigious society it is apparent that subjects such as informed consent, access to care, confidentiality, rights, best interests, autonomy/competence, withholding and withdrawing medical care are more open to public scrutiny and possible legal challenge.

This exercise will also usefully show that what may be legal may not be moral and what may be moral may not be legal. History abounds with examples that support this position; once (not so long ago) there was no right for women to vote in the UK or for gay men to give physical expression to their sexuality. A pressing example from the contemporary arena is assisted dying and voluntary euthanasia. Proponents argue it is both a moral and a humane concept that liberates an individual’s self-governance about the manner and time of death – it has, however, no legal standing. Advanced decisions that give an indication of an individual’s care wishes may, however, need to be heeded (Katsetos & Mirarchi 2011).

Given that nurses have a legally enforced duty of care towards patients within the emergency care setting, its seems fitting that a chapter dealing with ethics should begin by considering the notion of ‘duty’ as a central theme in the development of a school of ethical analysis called ‘deontology’. During this process, strong parallels will be drawn between deontology, duty as a traditional motivational force in nursing and, also, the Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives.

Duty as a moral endeavour

The historical dimensions of nursing are engulfed by the notion of duty. This tradition is succinctly entwined in the most central of nursing edicts, ‘a duty of care’. Within contemporary nursing there remains a strong allegiance to this theme. This approach is based upon the intrinsic and inalienable relationship that exists between ‘rights’ and ‘duties’. Broadly speaking, once a duty of care has been established, the patient has a right to be cared for and the nurse must facilitate care giving – this is both a legal and moral theme.

The Nursing and Midwifery Council (2008) Code encourages high standards during professional endeavours and expects all practitioners to operate within its framework and guidelines. In the edition published in 2008 the Code of Professional Conduct underwent a name change and has become the Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. The principle that nursing practice is inextricably linked with ethics cannot be ignored.

In the UK, the Nursing and Midwifery Council is the organization set up by Parliament to protect the public by ensuring that nurses and midwives provide high standards of care to their patients and clients. It is the regulatory body responsible for identifying the standards of these professions and requiring members of the professions to practice and conduct themselves within the standards and framework provided by the Code. Honesty and ethics are included in the list of the Nursing and Midwifery’s core values.

Statements made in the code of professional conduct serve to reinforce notions of duty and the statements made within the code provide motivational guidelines for nursing actions. Basing actions upon duties, rules or motives has a long history in ethics and is known as deontology. As Kendrick (1993) observes ‘this school of ethical analysis maintains that being moral entails acting from a sense of moral duty, respecting others’ rights and honouring one’s obligations.’

This interpretation clearly aligns itself with the themes of the Nursing and Midwifery Council (2008) Code and the onus that it places upon registered practitioners. The person most closely associated with deontology is the philosopher Immanuel Kant. He was a prolific writer and fervently advocated that people had intrinsic worth and value. Furthermore, he argued that an essential part of being human was the ability to use reason in deliberating over the moral worth of an action. For Kant, this ability invariably found itself rooted in a sense of duty.

There are many attractive elements of Kantian ethics. In particular, it places a great deal of emphasis upon respect amongst persons and encourages a fervent sense of individual duty. Tschudin (1986) summarized these themes by stating ‘a right action is only so if it is done out of a sense of duty, and the only good thing without qualification is a person’s good will: the will to do what one knows is right’.

Kant devised a complex moral theory, consisting of three formulations, that he called the categorical imperative. Their precise interpretation and mutual relations are a matter of controversy. Kendrick (1993) simplified the different formulations as follows:

• an action is only moral if you are willing for it to be applied to everyone, yourself included, as a universal law; ‘do as you would like to be done by’

• for an action to be moral it must never lead to people being seen just as ‘means to an end’ but always as ‘ends’ in their own right

• in wishing to be moral, individuals must act as members of a community where everybody is seen as having intrinsic worth (ends in their own right).

The essence of the categorical imperative can be readily applied to the duty-based nature of nursing; this will now be discussed with particular relevance to practice in emergency care.