Ethics/Integrity and Trust: Bridging the Gaps

My reaction when first approached to coedit this issue was, "But I'm not an expert in ethics!!" However, upon further reflection, I recalled initiating one of the first multidisciplinary ethics committees in nursing homes in the early 1980s. Those thoughtful reflective monthly meetings (and some called within hours as necessary to help families, residents, and staff) are some of the most memorable and challenging of my nursing career. Memories are vivid of the team helping several family members with diverse views make difficult decisions using surrogate decision-making principles when there had not been written wishes known for a severely physically and cognitively impaired person. Also, reviewing records for each resident following admission of their specific wishes for supportive care should the need arise after staff skillfully posed the important question of, "If this happens, what do you want us to do?" What I have brought to this issue is the practice and research perspective.

Leah H. Curtin is a nationally recognized expert in ethics. As she points out, professional ethics is the study of how personal moral norms apply or conflict with the promises and duties of one's profession. It does require a separate moral standard of conduct in that the choices professionals make affect other people's lives more than their own. Generally speaking, the kinds of choices that fall within this context encompass (1) the human rights of the patient and the degree to which he or she is capable of exercising them; (2) choices about the technical options available and their appropriate application to the human being as well as the "value options" open to patients about whether or not and to what extent they want or reject the technical options; (3) choices about research and learning on human beings; (4) choices about resource allocation in situations of scarcity; (5) choices about futile care and patient autonomy; (6) choices about the preeminence of one's own self-interest-ranging from exposure to biological and other workplace hazards to recompense for services rendered to weighing the institution's interests into the equations; and (7) questions of law and regulation-what they should be and whether and to what extent to comply, especially when they are at odds with the patient's best interests.

Codes of ethics came into being-as did almost all early laws-to protect the vulnerable from the powerful; the unwary from the unscrupulous. In ancient Summaria, Hammarabi incorporated a canon on medical ethics into his Coda; in China, the emperor addressed appropriate medical conduct in the Nei Ching; and in Greece, the Pythagoreans are credited with writing the Hippocratic Corpus. The Greek, Galen, and the Jew, Maimonides, expected-nay, demanded-high moral character of healers, but only India's Charaka Samhita (1st century AD) attributed moral as well as scientific authority to the healer.

The very word "profession" (L. profitere-to proclaim publicly) was derived from the medical acolytes' public promise of altruism and master craftsmanship-both of which were designed to protect a vulnerable public from both the unscrupulous and the incompetent. Then, as now, the total situation for patients (L. patientia-one who suffers) includes not only the diagnosis and treatment but also whether or not someone will stand by them through the course of their illness or death. However, then practitioners could do little to alter this course; thus the early codes stressed fidelity of the practitioner to the promises of the profession. 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 a more modest sharing of information and decision making: 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?

It is quite easy to justify-for the sake of financial security, for the sake of research, for the sake of the "greater good," even for the sake of our own intellectual curiosity-sacrificing the comfort, well-being, even the very safety of those entrusted to our care. Even, or most particularly because, they are in our power. The authors in this issue grapple with various aspects of ethics in the contemporary work setting; and while they may not have all the answers, they offer interesting perspectives, alternatives, and a wide variety of pragmatic resolutions for what can increasingly be seen as the everyday world of management of health service delivery!!

As coeditors, we have collected a broad range of topics to challenge readers to reflect about their practice-be that administrative, clinical practice, education, or research-all having enormous implications for the important core values of ethics, integrity, and trust.

Leah L. Curtin, DSc(Hon), RN, FAAN

Editor-in-Chief The Journal of Clinical Systems Management Clinical Professor of Nursing, University of Cincinnati College of Nursing Cincinnati, Ohio

Marilyn Rantz, PhD, RN, FAAN, NHA

Professor, Sincliar School of Nursing University of Missouri - Columbia, Columbia