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REPORT

‘The Globalisation of Nursing: Ethical, Legal and Political Issues’ University of Surrey 10�/11 July 2006: A summary of the deliberations of the concurrent working groups

Leila Toiviainen

Introduction

When we examine aspects of the globalization of nursing from ethical, legal and political perspectives, human rights comes to the fore as the concept on which other ideals and plans for concrete action must necessarily be based. This became evident in the discussions of the concurrent working groups at this year’s conference at the International Centre for Nursing Ethics. Nurses need to understand what the fundamental human rights of every person in the world ought to be, regardless of where they live, or what their religion or skin colour is. Nurses play a role in ensuring that these rights are respected, and support the struggle of those people who do not have the rights or the respect that should go with it.

Globalization of the nursing work-force means that nurses travel to work in numerous developed and developing countries of the world. In many of these countries the human rights of patients are not respected, either by governments or public and private organizations; the nurses themselves may not be able to demand their human rights as individuals.

Once nurses have developed an understanding of the human rights that determine the place of their patients and of themselves in the world, they need to develop plans for how they can actively promote these rights in their daily work and what to do when they are infringed.

The disparities in standards of health care and in access to health care are of major concern for nurses everywhere; their human rights work must be aimed at alleviating and eradicating these. The theme of International Nurses Day, 14 May 2004, was the eradication of poverty and hunger. At the time, 50% of the world’s population lived on less than $2 a day, 1.2 billion people did not have access to safe water, 24 000 people a day, mostly children, died of hunger, 54 countries were poorer than in 1990, and 70% of the world’s poor were women.1 The situation has not improved in the last two years; life expectancy in Japan is 85.3 years whereas in Sierra Leone it remains at 35.7 years.

Address for correspondence: Leila Toiviainen, School of Philosophy, Faculty of Arts, University of Tasmania, Private Bag 41, Hobart, Tasmania 7001, Australia. Tel: �/61 3 62262254; Fax: �/61 3 62267847; E-mail: [email protected]

Nursing Ethics 2007 14 (2) # 2007 SAGE Publications 10.1177/0969733007073708

Nurses can alter the effects of these global disparities, but only if they learn to understand the causes of them and then want to diminish the suffering behind these statistics with practical measures.

Caring for human rights in nursing

There were human rights working groups at the conference; other groups discussing the work of the International Council of Nurses (ICN) and non-government organizations (NGOs), as well as the those dealing with issues of public health, labour markets and war and terrorism, touched on similar concerns about justice and equity of access to work and health care.

In the group discussions it became clear that there is a tension between what people should expect as a right or as an entitlement. The confusion between ethical and legal rights was also addressed by members of the human rights working groups. These issues were raised in particular by Mark Chamberlain in his paper ‘The right to health: challenges and opportunities for nurses’. His presentation was based on Amnesty International’s report Caring for human rights: challenges and opportunities for nurses and midwives2 Members of the discussion groups asked whether the right to health was the same as the right to health care. According to the International Covenant on Economic, Social and Cultural Rights, as explained by Chamberlain in his paper, the right to health contains both freedoms and entitlements; the latter means having the right to a system of health protection.3

More than 150 countries have signed the International Covenant on Economic, Social and Cultural Rights. As signatories they are required to report on progress towards the Millennium Development Goals. Many members of the discussion groups pointed out that the guidelines contained in the covenant were advisory, rather than obligatory, and therefore not legally binding on the nations. Many nurses recognized that it was difficult for them to engage in political action because they were already working too hard to reconcile their work and family commitments. Many of them, however, raised issues regarding health promotion that are closely linked to human rights. They were concerned about the power of both the tobacco industry and the pharmaceutical companies, whose unethical and misleading advertising is directed specifically at the less literate or less discriminating individuals in both the developed and the developing countries. There are five million deaths a year world-wide attributable to tobacco; it is the second major cause of death. In comparison with this, deaths from HIV/AIDS amount to 3.1 million annually in the world.

Many conference delegates were familiar with the work of Marcia Angell in raising concerns about the power of drug companies; they sell chemical solutions for psychic distress caused by the social ills of the world. Her new book draws attention to the estimated total of world-wide sales for prescription drugs, which was about $400 billion in 2002, about half of this in America.4 The response of sensitive individuals to disparities of wealth and well-being is normal and should not be sedated out of existence. The social ills need curing, not individuals caring about them. Members of the working groups were concerned about the way in which pharmaceutical companies use individuals in developing countries for drug trials; it is debatable whether informed consent can be obtained from people who cannot read but who are desperate for any medications in the absence of any form of public health system. According to the International Covenant on Economic, Social and

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Cultural Rights, individuals should be free from non-consensual medical treatment and experimentation.

Some nurses underlined the high cost of whistleblowing on their careers and private lives in cases where they had detected illegal and unethical practices and had been brave enough to speak up against them. Many were aware of the case of the Australian nurse, Toni Hoffman, who revealed the unprofessional practices of a surgeon in Queensland, who not only infringed the human rights of his patients but caused the deaths of several of them. In spite of this Hoffman was vilified as a troublemaker by her colleagues and senior nurses for two years before any action was taken against the surgeon.5 This example illustrates the fact that it is impossible for nurses to care effectively for the human rights of their patients if their right of free speech and their right to ethical actions demanded by their profession are not respected.

The human rights of nurses

ICN statistics for 2004 show that 70% of the world’s poor are women; many of these women must be nurses. The working groups on the ICN and on NGOs addressed issues related to the work of nurses for organizations such as Oxfam, who have a code of conduct for their staff so that the cultural, social and religious sensitivities of the host nations are respected. It was pointed out by Gosia Brykczynska, the former International Officer of the (UK) Royal College of Nursing, that this did not, however, amount to ethical relativism on issues such as female genital mutilation. The fact that it is still practised in some African countries does not make it right. The World Medical Association and organizations collaborating with it are committed to working for the eradication of this practice (see the News section in this issue for a statement by the ICN on this topic). Nurses must be clear, then, what kinds of things count as harmless cultural practices and why others are global ethical and legal issues to do with the basic human rights of individuals everywhere. Only if they know what is right and wrong in particular instances can they prevent harm and fatal injuries to vulnerable people.

Although nurses around the world are generally respected as professionals and those in developed countries take their own human rights for granted, this is not the case in all countries. Leyla Dinç, from Turkey, explained that in her country nurses’ status is linked to the status of women in an Islamic society, with its own traditions and values. In this culture women are considered as having less value than men, who dominate the public sphere, and women are expected to remain in the private sphere of home and family. An example of an ethical dilemma faced by nurses in Turkey is the virginity examination of young women, especially in rural areas. Although the Turkish Nurses Association does not support such examinations, not to participate in them may well put young women at grave risk.

Members of the working groups also highlighted the fact that nurses doing the same work in the same country do not receive the same salaries or the same respect as professionals. Filipino and Indian nurses in Saudi Arabian hospitals are paid less than their Canadian, American, Australian and British counterparts doing exactly the same nursing work, caring for the same patients. The conference participants also reiterated their view in several contexts that it is wrong for wealthy developed countries to poach trained nurses from poorer developing countries, where they are badly needed to care for the basic health needs of large populations.

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Leroi Henry of the (UK) Open University, in his paper, ‘Disengagement and demoralisation’, illustrated the discrimination of Ghanaian nurses working for the National Health Service in the UK. He has conducted interviews with nurses and midwives who trained in Ghana but who now work in Britain. They feel discriminated against because they are not promoted on merit, as ‘promotion into management (grade G and above) involves navigating systems of patronage and sponsorship based on meeting subjective and culturally specific criteria’. Nurses cannot respect the human rights of their patients in situations in which they are unable to accord the basic dignity they deserve to their own colleagues. As Henry concluded, racism in the work- place exists not only in the minds of the nurses subject to it; its existence in the National Health Service cannot be denied. What is needed to eradicate racism and discrimination in health services is an analysis of why it occurs and how individual nurses at different levels of the hierarchy respond to it. As a result of this analysis, practical steps to prevent it must be put in place; nurses should advocate for their vulnerable patients and colleagues, not expose them to more harm.

Ethical, legal and political issues in globalized nursing

Nurses in a more globalized world have to undertake two kinds of tasks that appear to be in conflict with each other. On one hand they need to be aware of the cultural values of the country in which they work and try to avoid offending employers and patients who hold different perspectives on the relationship between health and human rights. On the other hand they have to work towards the promotion and maintenance of universal human rights on which ethical health care should be based.

Even though I have singled out the work of Ghanaian nurses in England subjected to racism and the work of Turkish nurses in their own country governed by patriarchal structures in the above discussion of the working groups at the Guildford conference, I was nevertheless left with the general impression that the dominant paradigm of these debates was that of Anglo-American bioethics. Those members of the groups whose first language is not English were often at a disadvantage; they could not fully follow the discussions or participate in them equally. In the remaining section of this summary I want to highlight the views of particular participants who spoke most memorably about how the many disparities in human rights and health care could be addressed in practice. In his paper, ‘A global basis for nursing ethics in a culturally complex world’, Richard Rowson, an English philosopher, began by stating that:

With the increasing globalisation of nursing, as nurses move from culture to culture and nursing organisations deal with nurses and patients from many different societies, there is growing uncertainty as to the ethical basis on which these organisations should operate. A professional organisation cannot work effectively if its members adhere to different values, but in the culturally complex world of nursing it can be difficult to know what these core values should be.

Much of the two-day conference was spent in search of these core values, in an effort to find a common language in which to express desiderata for universal practices. Rowson proposed that our search should begin from the understanding of what ‘the fundamental objective of nursing’ is. He argued that this should be ‘promoting the health of, and caring for, people of all sections of society’. To this I would add that this should apply to all places at all times; I agree with Rowson that otherwise we put the

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fundamental objective of nursing at risk and therefore endanger the physical and mental health of our patients and harm our own professional integrity.

Using the example of an encounter between an Aboriginal woman and scientists exploring the coast of Western Australia in 1801, Jocelyn Dunphy Blomfield discussed in her paper, ‘A basic problem in inter-group ethics: dealing with underlying values’, the issues of power and exploitation in colonialism; two sets of values come into conflict. She argues that similar sets of values were still evident at the biennial ICN Congress in Taipei in May 2005, but acknowledges that, ‘Within well-functioning work- groups there will be conflicting values’. These cannot be ignored or erased by the more powerful members of the group; it is their responsibility to ensure that the views of those who are less powerful are understood and respected; this is different from ‘mere tolerance and neutrality’. Likewise, in nursing, both parties to a discussion have to be willing to go further towards the viewpoint of others in order to enhance their understanding and respect of the values and cultures of others. The solution to a practical problem that arises from such deliberations cannot be a consensus cobbled together from the remnants of past positions but a true valuing of the fundamental objective of nursing. On this account, practices such as female genital mutilation or the death penalty �/ an issue raised by some North American delegates to the conference �/

cannot be right in any culture in any country. On a fundamental level then, we are not talking about human rights in the abstract, but about the equal value of each human life in the concrete. No human being anywhere in the world today should die of hunger, malnutrition or poverty, even less as a victim of violence and war.

The most plausible alternative perspective to the western materialist notions of health care and human rights was brought to the conference by the president of the Nurses Association of Thailand, Jintana Yunibhand. She highlighted the breadth of Buddhist values in how they work not only in nursing but in the daily lives of Buddhists in Thailand and elsewhere in Asia. If the fundamental objectives of Buddhist nursing are founded on harmony with nature and compassion, then to harm any human being or any other living being violates these precepts. Many western health care practices are based on the exploitation of others for financial gain, such as of nurses from poor countries as an expendable work force by richer nations and the use as research subjects of individuals, both human and animal, who cannot give their informed consent and who do not benefit from this research.

Conclusion

The Globalisation of Nursing conference held at the International Centre for Nursing Ethics at the University of Surrey in July 2006 highlighted the difficult working conditions of many nurses around the world, some of whom were delegates at Guildford. Those of us who were fortunate enough to participate and learn from our colleagues should work towards the human rights and health care of those colleagues and patients whose lives are damaged and destroyed by poverty and lack of health care. We learn best in dialogues in which we are willing to listen to the views of others who we initially perceive as different from ourselves. Only then can we develop an understanding of our common humanity that does not know any political boundaries, and of our place in nature as a part of it. Only as a result of gaining true insights into the feelings of others can we work for the promotion of human rights in the context of nursing and its fundamental objective.

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Leila Toiviainen, University of Tasmania, Australia, and Helsinki University, Finland, and Regional Editor for Nordic Countries, Nursing Ethics.

References 1 International Council of Nurses. ICN on poverty and health: breaking the link [Fact sheet]. n.d.

Retrieved 29 May, 2005, from: http://www.icn.ch/matters_poverty.htm 2 Amnesty International. Caring for human rights: challenges and opportunities for nurses and

midwives. 2006. Retrieved 20 August, 2006, from: http://www.amnesty.org./library/Index/ ENGACT750032006

3 Amnesty International. Caring for human rights: challenges and opportunities for nurses and midwives. Appendix 2: Health rights in international and regional human rights standards. 2006: 41�/73. Retrieved 20 August, 2006, from: http://www.amnesty.org/library/Index/ ENGACT750032006

4 Angell M. The truth about the drug companies: how they deceive us and what to do about it. Random House, 2005.

5 Australian Broadcasting Corporation. Australian story: at death’s door. 27 June, 2005. [Television programme transcript.] Retrieved 18 August, 2006, from: http://www.abc.net.au/austory/ content/2005/s1400735.htm

Editor’s note:

A press release written at the end of the conference was disseminated widely. The text is printed below. Any readers are welcome to use it.

PRESS RELEASE

International Nurses Express Global Concerns

Public statement from international nurses at the conference on ‘The Globalisation of Nursing’ organised by the International Centre for Nursing Ethics, University of Surrey, UK, taking place at the university on 9�/11 July 2006.

As nurses and nurse educators from about 20 countries* we have spent two intensive days examining the impact of globalisation on health and healthcare. Millions of nurses throughout the world have the especially responsible position of frontline workers and professionals caring for and preventing human suffering. We take our social responsibility seriously. We are concerned that the delay and neglect of key international agreements will exacerbate the growing global healthcare crisis and undermine the sustainability of nursing itself. We therefore call on our national governments and the relevant international organisations fully, diligently and urgently to respect, implement and enhance the international agreements on the human right to healthcare, on economic justice and on the mitigation of climate change.

*Australia, Canada, China, Finland, Israel, Japan, Jordan, Korea, Nepal, Netherlands, New Zealand, Slovenia, Sweden, Tanzania, Thailand, Turkey, United Kingdom, USA

Contact: Dr Verena Tschudin [email protected] 020 7351 1263 or: Prof. Geoffrey Hunt [email protected] 020 8979 8616

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.