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Ethical Issues in Nursing

This book examines major ethical issues in nursing practice. It eschews

the abstract approaches of bioethics and medical ethics, and takes as its

point of departure the difficulties nurses experience practising within

the confines of a biomedical model and a hierarchical health care

system. It breaks out of the rigid categories of mainstream health care

ethics (autonomy, beneficence, quality of life, utilitarianism…) and

provides case studies, experiences and challenging lines of thought for

the new professional nurse.

The contributors examine the role of the nurse in relation to themes

such as informed consent, privacy and dignity, and confidentiality.

Nursing accountability is also considered in relation to the

contemporary Western health care system as a whole. New and critical

essays examine the nature of professional codes, care, medical

judgement, nursing research and the law. Controversial issues, such as

feeding those who cannot or will not eat, the epidemiology of HIV and

dilemmas of choice and risk in the care of the elderly are tackled

honestly and openly.

Geoffrey Hunt is the first philosopher to have been employed by the

National Health Service. In 1992, his controversial National Centre for

Nursing Ethics at the Hammersmith Hospital was closed down,

reopening in 1993 at the University of East London. He has published

widely in social philosophy and the ethics of health care.

Professional Ethics

General editors: Andrew Belsey and Ruth

Chadwick

Centre for Applied Ethics, University of Wales

College of Cardiff

Professionalism is a subject of interest to academics, the general public

and would-be professional groups. Traditional ideas of professions and

professional conduct have been challenged by recent social, political

and technological changes. One result has been the development for

almost every profession of an ethical code of conduct which attempts to

formalise its values and standards. These codes of conduct raise a

number of questions about the status of a ‘profession’ and the

consequent moral implications for behaviour.

This series, edited from the Centre for Applied Ethics in Cardiff,

seeks to examine these questions both critically and constructively.

Individual volumes will consider issues relevant to particular

professions, including nursing, genetic counselling, journalism,

business, the food industry and law. Other volumes will address issues

relevant to all professional groups such as the function and value of a

code of ethics and the demands of confidentiality.

Also available in this series:

Ethical Issues in Journalism and the Media

Edited by Andrew Belsey and Ruth Chadwick

Ethical Issues in Social Work

Edited by Richard Hugman and David Smith

Genetic Counselling

Edited by Angus Clarke

The Ground of Professional Ethics

Daryl Koehn

Ethical Issues in Nursing

Edited by

Geoffrey Hunt

London and New York

First published 1994

by Routledge

11 New Fetter Lane, London EC4P 4EE

This edition published in the Taylor & Francis e-Library, 2005.

“To purchase your own copy of this or any of Taylor & Francis or Routledge’s

collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

Simultaneously published in the USA and Canada

by Routledge

29 West 35th Street, New York, NY 10001

Introductory and editorial material © 1994 Geoffrey Hunt; individual chapters ©

1994 individual contributors; this collection © 1994 Routledge

All rights reserved. No part of this book may be reprinted or reproduced or

utilized in any form or by any electronic, mechanical, or other means, now

known or hereafter invented, including photocopying and recording, or in any

information storage or retrieval system, without permission in writing from the

publishers.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

Library of Congress Cataloguing in Publication Data

Ethical Issues in Nursing/edited by Geoffrey Hunt. p. cm.—(Professional

ethics) Includes bibliographical references and index. 1. Nursing ethics. I. Hunt,

Geoffrey II. Series. [DNLM: 1. Ethics, Nursing. WY 85 E838 1994] RT85.E82

1994 174'.2–dc20 93–34921

ISBN 0-203-41842-5 Master e-book ISBN

ISBN 0-203-72666-9 (Adobe eReader Format)

ISBN 0-415-08144-0 (hbk)

ISBN 0-415-08145-9 (pbk)

Contents

Series editors’ foreword vii

Notes on contributors ix

Acknowledgements xi

Introduction: Ethics, nursing and the metaphysics

of procedure

Geoffrey Hunt

1

Part I: Specific issues

1 Nursing and informed consent: An empirical study

Deborah Taplin

21

2 The observation of intimate aspects of care: Privacy

and dignity

Paul Wainwright

39

3 Choice and risk in the care of elderly people

Linda Smith

57

4 Caring for patients who cannot or will not eat

Julie Fenton

75

5 Disabled people and the ethics of nursing research

Maddie Blackburn

93

6 Ethical issues in HIV/AIDS epidemiology: A

nurse’s view

Ann Kennedy

109

Part II: General issues

7 Nursing accountability: The broken circle

Geoffrey Hunt

131

8 The value of codes of conduct

Andrew Edgar

149

9 In the patient’s best interests: Law and professional

conduct

Ann P.Young

165

10 Nursing and the concept of care: An appraisal of

Noddings’ theory

Linda Hanford

181

11 ‘Medical judgement’ and the right time to die

Anne Maclean

199

12 Nurse time as a scarce health care resource

Donna Dickenson

209

Bibliography 221

Index 231

vi

Series editors’ foreword

Applied Ethics is now acknowledged as a field of study in its own right.

Much of its recent development has resulted from rethinking traditional

medical ethics in the light of new moral problems arising out of

advances in medical science and technology. Applied philosophers,

ethicists and lawyers have devoted considerable energy to exploring the

dilemmas emerging from modern health care practices and their effects

on the practitioner-patient relationship.

But the point can be generalised. Even in health care, ethical

dilemmas are not confined to medical practitioners but also arise in the

practice of, for example, nursing. Studies of ethical issues in nursing,

such as those contained in this book, have a vital role to play as nurse

education and nursing practice change in parallel to new conceptions of

health care delivery. Beyond health care, other groups are beginning to

think critically about the kind of service they offer and about the nature

of the relationship between provider and recipient. In many areas of

life, social, political and technological changes have challenged

traditional ideas of practice.

One visible sign of these developments has been the proliferation of

codes of ethics, or of professional conduct. The drafting of such a code

provides an opportunity for professionals to examine the nature and

goals of their work, and offers information to others about what can be

expected from them. If a code has a disciplinary function, it may even

offer protection to members of the public.

But is the existence of such a code itself a criterion of a profession?

What exactly is a profession? Can a group acquire professional status,

and if so, how? Does the label ‘professional’ have implications, from a

moral point of view, for acceptable behaviour, and if so how far do they

extend?

This series, edited from the Centre for Applied Ethics in Cardiff and

the Centre for Professional Ethics in Preston, seeks to examine these

questions both critically and constructively. Individual volumes will

address issues relevant to all professional groups, such as the nature of a

profession, the function and value of codes of ethics, and the demands of

confidentiality. Other volumes will examine issues relevant to particular

professions, including those which have hitherto received little attention,

such as journalism, social work and genetic counselling.

Andrew Belsey

Ruth Chadwick

viii

Notes on contributors

Maddie Blackburn is Research Health Visitor in the Community

Paediatric Research Unit, Chelsea and Westminster Hospital, London.

Donna Dickenson lectures in the Department of Health and Social

Welfare at the Open University, Milton Keynes. She is the author of

Moral Luck in Medical Ethics and Practical Politics, Avebury, 1991.

Andrew Edgar lectures in philosophy at the University of Wales

College of Cardiff and is a member of the Centre for Applied Ethics

at the university.

Julie Fenton is a Senior Dietitian, employed by Richmond,

Twickenham and Roehampton Health Authority and working with

people with learning difficulties. At the time she wrote her chapter

she was working within the Mental Health Unit, Wandsworth Health

Authority, London.

Linda Hanford is Head of the Department of Health Studies at the

University of East London, London and Deputy Director of the

European Centre for Professional Ethics.

Geoffrey Hunt is Director of the European Centre for Professional

Ethics at the Institute of Health and Rehabilitation, University of East

London, London. He has previously lectured in philosophy at the

Universities of Swansea, Cardiff, Ife (Nigeria) and Lesotho.

Ann Kennedy is presently pursuing full-time doctoral studies at the

London School of Hygiene and Tropical Medicine, University of

London. She was previously Senior Research Nurse at St Mary’s

Hospital, Paddington, London.

Anne Maclean lectures in philosophy at the University College of

Swansea. She previously lectured in philosophy at Newcastle

University and Queen’s University, Belfast. She is the author of The

Elimination of Morality, published by Routledge.

Linda Smith is a Lecturer-Practitioner in Nursing, based at the

Hammersmith Hospital and is a specialist in care of the elderly and in

nursing research.

Deborah Taplin is Lecturer-Practitioner in Nursing, based at the

Hammersmith Hospital and is a specialist in critical care.

Paul Wainwright is Programme Manager (Graduate Studies) for the

Mid and West Wales College of Nursing & Midwifery, University

College of Swansea. Before that he was a professional officer with

the Welsh National Board for Nursing, Midwifery and Health

Visiting, in Cardiff.

Ann P.Young is Deputy Registrar, The Nightingale and Guy’s

College of Nursing and Midwifery, Guy’s Hospital, London and the

author of several books on legal aspects of nursing.

x

Acknowledgements

I am especially grateful to nurse educators and nurses at the

Hammersmith Hospital, London for warmly welcoming me, a social

philosopher, into the National Health Service environment. As the first,

and possibly the last, philosopher employed by the National Health

Service I am lucky that I was allowed to be a gadfly for as long as two

years. The University of East London had sufficient foresight to make it

possible for me to continue my work.

Some formal acknowledgements are due. Julie Fenton’s article arose

in part from participation in the Royal College of Nursing’s Nutrition

Consensus Conference in November 1991. The views expressed in this

article should not be taken to be representative of those of the Royal

College of Nursing (RCN) or its Working Party on Nutritional

Standards for the Older Adult. Thanks go to the Association for Spina

Bifida and Hydrocephalus, for allowing the use of some of Maddie

Blackburn’s research materials in her chapter. I am grateful to the

Nursing Standard for permission to use sections from my three articles

on accountability: ‘Professional Accountability’, 1991, vol. 6 (4), pp.

49–50; ‘Upward Accountability’, 1992, vol. 6 (16), pp. 46–7;

‘Downward Accountability’, 1992, vol. 6 (21), pp. 44–5.

Bob Carley and Yvonne Bastin gave me help with alacrity in the

nursing library at the Hammersmith Hospital. I thank Dr Ruth

Chadwick and Mr Andrew Belsey of the University of Wales College of

Cardiff for inviting me to edit this volume in their series.

I extend my warm appreciation to my friends Chris Stephens, Mike

Cohen, Anne Maclean, and Colwyn Williamson for sharing times which

were sometimes arduous, sometimes hilarious, but always very much

alive.

Geoffrey Hunt

xii

Introduction

Ethics, nursing and the metaphysics of procedure

Geoffrey Hunt

A PERENNIAL PREDICAMENT

On the whole the chapters in this volume adopt a standpoint which is

rather different from the abstract rationalising standpoint of bioethics.

More to the point, their approach is also somewhat different from that

of mainstream medical ethics.

Throughout the chapters there appears some manifestation of that

tortured predicament which has characterised nursing throughout its

history. This predicament is either openly acknowledged and informs

the thrust of the essay or it resides in underlying assumptions which

give rise to certain unresolved difficulties and inadequacies. If I may

put the predicament of nursing in overstated form for the sake of clarity:

people, usually women, are given the special role of caring for other

people on condition that they do so only under general direction from

experts in the workings of the bodies of Homo sapiens and organised by

experts in the management and administration of the mass treatment of

these bodies. The perennial question posed is whether such means are

adequate to the professed end. Is caring (not ‘treatment’, not ‘curing’ but

caring) possible under such conditions? Is it possible only with great

difficulty, heroic effort and exceptional people? The question perhaps is

not whether it is possible, for the common decency and sometimes the

heroic effort of individual nurses make it possible on a daily basis. The

possibility is realised despite the health care system, not because of it. The

proper question then is whether such a conception and such an

arrangement facilitate caring or constantly work against it?

Naturally, the reality of nursing is far from being simple. The

predicament is not always acutely felt and takes various forms. Many

different activities, in many different kinds of setting, go under the

name of nursing. Some nurses work in the community and others in

research hospitals, some work with people who are well—trying to

prevent illness—and others work with people who are critically ill but

may make a full recovery, while yet others care for people who must

shortly die. Some still work on large ‘Nightingale wards’ while others

work in a small nursing home or hospice, and some work in large and

constantly changing teams while others work in a ‘primary nursing’

manner. Some nurses work under great difficulties caused by an

inflexible and hostile administrative regime or shortage of resources or

both, while others are much luckier.

But through it all, I think, a general picture does emerge. In the

hundreds of classroom and workplace discussions I have had with nurses,

formally and informally, I have learned to distinguish between what is

recurrent and systemic, and what may be put aside as peculiar,

untypical or secondary.

Nurses often express unease about a lack of freedom to care for

patients and clients as they feel is decent, as they feel they themselves

would like to be cared for or have their loved ones cared for. Many, but

not all, of the ethical issues they raise come back to this unease in one way

or another. More often than not discussions end up in an exploration of

the constraints on their freedom to care. Two general and related

constraints, nearly always emerge: the way in which medicine defines

health and illness, reflected in the way doctors think about and

‘approach’ people in care (the ‘biomedical model’); and the way in

which the whole business of health care, including nursing, is organised

in a military-style command structure in which technical experts have

the power (hierarchical technocracy). I am not suggesting any unanimity

about this. Some nurses, usually the more senior ones disagree with me.

They insist that there is nothing wrong as long as ‘the professions’

(medicine, management, nursing, etc.) ‘respect’ one another and work

together in a ‘team’. I suspect that in truth co-operation is limited and is

for ever undermined by these deeper tensions and inconsistencies.

PROCEDURE

At a deeper level a source of a wide range of difficulties is the

domination of nursing by a metaphysics of procedure, as is typical of

administrative work in the civil service. Although it is true that

individual nurses are highly respected, some are quite powerful, some

are listened to carefully by doctors (especially junior doctors) and some

care settings have good multidisciplinary policies, there is a strong

general trend in nursing as a whole to keep an exaggerated

2 INTRODUCTION