July 30, 2014
Douglas Olsen is an associate professor in the College of Nursing. An expert in research ethics, he was chairman of the Yale School of Nursing IRB for more than 10 years and was ethics advisor to the VA Central Institutional Review Board for four years. He has been involved in developing and interpreting national ethics policy at the VA’s National Center for Ethics in Health Care and worked with international colleagues at the International Centre for Nursing Ethics, based at the University of Surrey, and with the journal Nursing Ethics. Since coming to Michigan he has worked with the Michigan Protection & Advocacy Services on mental health issues and in August will be joining leaders in the field of nursing ethics in an invitational conference at Johns Hopkins to look at the development of a national and international agenda for the field.
Nursing uses science to enact values, and for me, the core professional value of nursing is caring concern for others. To enact that value to its fullest, nurses need the best science of health and disease, and rigorous ways to judge the degree to which we have maximized the potential of caring concern for others when giving nursing care.
In many ways, nursing ethics may still be in its infancy. Nurse theorists have made significant achievements advancing the concepts of caring and relational ethics. Still, most nurses continue to learn ethics as derived from medical ethics and often in ways that have little relevance to nurses. At MSU, we are working to address this in the new curriculum being developed at the College of Nursing, which will incorporate both ethical conduct in relationships and resolution of ethical uncertainty and conflicts.
I try to write about issues with direct bearing on nursing practice, such as discussing short staffing with patients and the appropriateness of patients seeing nurses bedecked with items, some clinically useful and others trivial, bearing drug company logos.
I also use my position as contributing editor for ethics at the American Journal of Nursing to bring out the relational aspects of ethics, such as the meaning of gift-giving in live organ donations arranged over the internet or the value of trust when considering a deception, or attempting therapeutic use of relationship to reach mutual resolutions when patients refuse nursing care before debating black-and-white responses ostensibly based on rights.
Nurses encounter cases in which the right course of action isn’t clear—should nurses be required to get the flu vaccine to keep their jobs? Or, the course being followed just doesn’t feel right—should military nurses be force-feeding detainees at Guantanamo Bay? Or, nurses feel as if there might be a better way to express the value of care for patients—is an appeal to patients’ rights the best approach to a bed-bound patient that refuses turning? These are the types of situations I try to help nurses explore, and over the years, I learned a few lessons:
- Nurses enter the profession with the desire to care and they already have an intuitive understanding of ethics. Interviewing and talking to nurses, I find that they have ideas that are easily translated into the specialized language of ethical theory. I often find that a little training in ethics terminology can detach nurses from their deeper intuitive understanding of morality as encountered in nursing practice. In my teaching I encourage students to feel the underpinning of human values for concepts like “respect for patient autonomy,” that we value self-determination and so seek solutions that maximize a patient’s ability to meaningfully choose among realistic alternatives.
- However, expressing gut feelings isn’t enough—only rigorous justification carries weight. When I heard that some Michigan hospitals refuse to hire nurses who smoke, my initial reaction was that this didn’t feel like caring concern for either the nurses or patients, so I set out to examine the issue in a way that others could follow and agree or give reasoned argument.
- While ethical uncertainty in healthcare requires immediate concrete answers, they also involve the timeless questions that people have been asking since the beginning of history. For example, “What makes us human?” Many issues in ethics involve assessing a patient’s decision-making capacity to see if the patient or a surrogate should be making health care decision. Examples I’ve examined include hiding medication in food, giving informed consent for research in China, and restraint use in psychiatric nursing. We invoke “decision-making capacity” because the underlying assumption of Western thought is that rationality is the defining characteristic of humanity.
- Finally, I’ve learned that the Western perspective is not the only way to view conflicts in values. To expand and enrich nursing ethics we need to look to other cultures. We can get beyond what has become a stifling worldview dominated by autonomy as atomistic individualism in Western bioethics by working alongside those who hold alternate worldviews such as the African Ubuntu, where, in the words of Bishop Tutu, “a person is a person through other people.” Or the Japanese principle of harmony, or the Chinese of filial piety. I have been fortunate to have had the experience of being able to expand my perspective teaching ethics or helping with ethics research in Turkey, Russia, Japan, Lebanon, China and Hong Kong.
Development of nursing ethics continues to guide nursing practice, but is also essential to our society. Public discourse on health care policy is enhanced when the unique voice of nursing is articulated and brought to the table.