The increased presence of "ethicists" within clinical settings in the past 20 years raises questions about their sources of authority and norms of practice. Physicians are usually considered the primary clinical ethics facilitators at the bedside, yet nurses have much to offer this process. Nursing is a materialization of a value according to which it's morally good to promote physical and psychological well-being. Such a moral obligation involves making ethical judgments-and as nurses, we're best served by acknowledging our own contribution to the myriad of clinical ethics decision-making processes that confront us today in our varied practice settings.
All healthcare providers-nurses, physicians, dietitians, social workers, allied health therapists, and others-should participate in the shared learning and discussion of clinical ethics. Despite a certain suggestion in the medical literature that clinical ethics is the clinician's responsibility, our ethical lan- guage and concerns are common to all, and shouldn't be divided into unhelpful and marginalizing dichotomies. In particular, it's the nurse's ethic of advocacy that establishes a unique and invaluable contribution to the clinical ethics decision-making process.
Guiding principles
Four primary ethical principles-beneficence (to do good), nonmaleficence (first, do no harm), autonomy (self-rule), and justice (to treat persons fairly, without regard)-form the "principlist" approach as purported by Tom Beauchamp and James Childress's Principles of Biomedical Ethics (1979-2001). Through its five editions, this classic text and approach has largely been regarded as the mainstay of ethical principles in the healthcare setting.1
Two more principles should be added-compassion and advocacy-because it's via these nurse ethics that the four primary principles are enacted. Considering the physician domination of the clinical ethics literature, it's not difficult to assume a certain physician-only mindset when contemplating the questions as to who should "do ethics" at the bedside. Certain researchers clearly describe the physician as legitimating the clinical ethics process by explaining that physicians should share health- care decisions with well-informed patients who can understand their diagnoses, prognoses, and the various alternatives of proposed treatment and of nontreatment, and who can make decisions.2 Similarly, additional experts emphasize clinical acumen as being paramount to the clinical ethics process in that clinicians have practical expertise in the clinical arena. They provide the following suggestion on the central importance of the clinical ethicist's skills and judgment:
Skill in clinical judgment underlies effective consultation, enabling the consultant to make the medical distinctions that are technically and morally relevant in each case. The consultant considers the care of a particular patient in a particular circumstance with a particular illness, as particularity is the hallmark of good medical practice.3
This suggestion of a certain clinical acumen may be problematic for nonphysician ethicists such as philosopher ethicists and nurse ethicists. It raises the legitimacy of those nonphysician ethicists into question. It also hints on a certain encroachment of the nonphysician ethicist into the protected territory of clinical medicine. The literature concerning the supposed contributions of the nonphysician clinical ethicist is scant at best, which makes a thorough comparative analysis virtually impossible. There is, however, a reasonable representation within the clinical ethics literature on the contributions of two of the nonphysician ethicist groups-the nurse and the philosopher.
Not surprisingly, there's an overwhelmingly pro-nurse sentiment in clinical ethics consultation that's expressed in the nursing literature. The majority of supporters hold the view that nurses espouse a unique perspective on the ethics of healthcare, mainly due to their prolonged contact with the patient, therapeutic communication skills, and goal- oriented approaches to ethical decision making.4 Some nurses go as far as to suggest a distinctive nurse-ethicist model of ethics consultation.5 Similarly, others argue that nurses should take on a major role in bioethics because of the increasing scientific nature of medicine, and because of the unique and intimate relationship of nurses to patients, which is based on advocacy.6
Differing origins
What's the difference between medical ethics and nursing ethics? Nursing focuses on health, whereas medicine focuses on cure. Moreover, there's a functional distinction between care and healing. It's useful to first consider the history of nursing as it pertains to ethics. The historical influence on ethics might begin by considering Florence Nightingale's 1893 paper. Since then, nursing has ascribed to the ideals of treating persons rather than diseases.
The history of nursing is a history of nurses' endeavors to adhere to ideals of caring by fostering the patient's active role in treatment and prevention through education, home healthcare, improved personal hygiene and food handling, and better hospital conditions to reflect better the psychosocial aspects of illness.7 On the contrary, medicine offers an approach that underscores curing as a response to the occurrence of a disease, a paternalistic approach to medical decision making with the hospital as the center of best medicine.8
Further disparities in the professional approaches of nursing and medicine are worth noting. Nursing has essentially developed as a health-oriented profession that emphasizes the preservation and restoration of health to persons. Medicine, conversely, has arisen as an illness-oriented profession that gives emphasis to the treatment and prevention of disease, injury, and deformity through complex surgical, biochemical, and technical interventions.7 In contemporary practice, the typical physician/patient encounter is episodic in its consultative nature. For example, the physician obtains a medical history, reviews signs and symptoms of disease processes, obtains consent for proposed interventions, documents orders, supervises the training of other medical personnel in administering therapeutic procedures, reviews exam and test results, monitors clinical progress, and arrives at a diagnosis and therapeutic regimen. These activities are normally accomplished in short episodes and serve the goal of cure.8 In nursing, the interaction with the patient is in-depth and personal, focusing on values and adaptive/restorative processes. This interaction is a nurse's "ever- presence," that is, nurses there, 24 hours a day, 7 days a week, providing bedside care.9
Continuous nursing care lends itself not only to greater trust but also to advocacy-a perspective that shapes nursing ethics. Advocacy is more than passive listening. It's an active approach to communication. Processes and skills required to successfully advocate for patients include accountability, ethical analysis and decision making, knowledge of and adherence to clinical standards and legal definitions of nursing practice, health education and counseling, leadership, collaboration, communication, and ability to implement change.
Yet the crucial factor in everything is the nurse's ability to truly acknowledge and appreciate his or her own unique and invaluable perspective and contribution to the clinical ethics process-and to practically (and proudly) implement it. Recognizing the nurse's true value as a team player is imperative in this process; despite the subtle (and not so subtle) differences that impact upon medical and nursing ethics, there must be the recognition of an essential integration of healing and nurturing or curing and caring, for they are, after all, inseparable.
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