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Provision 1 • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • 1

Provision 1. Affirming Health through Relationships of Dignity and Respect

Introduction

There is, perhaps, no better place to begin a discussion of ethics in nursing than with attention to the momentous concepts of compassion and human dignity. Because of their magnitude and central importance to nursing, it warrants dwelling a moment on these concepts of compassion, suffering, and human dignity. That compassion responds to suffering is to be expected, as the word itself joins together the Latin com- (meaning together with) and pati (meaning to suffer), thus “to suffer with” another.1 Sharing the same root, the patient, also from the Latin pati—meaning to suffer or to endure affliction is the subject of compassion.2 This relationship between compassion and suffering has been a topic of intense reflection for millennia in both religious and philosophical literature.

Hinduism, in its urreligious (oldest, primeval, or proto) form, is thought to have its origins around 2,600 BCE and is sometimes referred to as “the oldest religion.”3 It has no single founder and is an amalgamation of numerous indigenous religions of the Indian subcontinent. It coalesces into a “Hindu synthesis,” that is, a more unified form, around the beginning of the Common Era.4,5 Hinduism would seem an odd place to start a discussion of compassion in modern nursing, yet 4,600 years of human observation and reflection can provide some astute insights of relevance to nursing.

Hinduism has not one but several words that translate into English as the single word compassion. Each has a subtle shade of meaning. The three most common words are daya (Hindi: दया), karuna (करुणा), and anukampa (अनुकम्पा ). 6 Daya is the first among the eight essential qualities of the soul that must be developed. It means “the desire of one’s bosom to mitigate the sorrow and

Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

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EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 4/4/2017 7:56 PM via STATE COLLEGE OF FLORIDA, MANATEE-SARASOTA AN: 1021763 ; Fowler, Marsha Diane Mary, American Nurses Association.; Guide to the Code of Ethics for Nurses with Interpretive Statements : Development, Interpretation, and Application Account: macc

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difficulties of others by putting forth any amount of efforts.” It is also defined as “…to treat a stranger, a relative, a friend or foe as one’s own self,” as someone who is as susceptible to suffering as I am. Karuna is “…born of grief on account of loss or difficulties of [persons] near and dear.” Anukampa means “to experience mild and gentle movement in the heart following the observance of pain and suffering in the other person.”7

It is evident from these definitions that they are based on critical reflection and address a number of pivotal underlying questions that are deeply relevant to nursing ethics. These questions include:

Is compassion a virtue? If so, what kind of virtue? Is it innate or learned? Can compassion be taught? Is compassion the same as sympathy or pity? Does compassion involve empathy or mercy? Is compassion a response? What is the function of compassion? Is compassion nothing more than a feeling? Is compassion a cognitive decision? Does compassion require tangible action? Who or what is the object of compassion? Who or what is worthy of my compassion? Is compassion toward one’s self or a loved on the same as compassion toward a foe? Need a person merit compassion? How does compassion relate to my own potential or real suffering? Is the one who expresses compassion in a superior position? Are there degrees of compassion? If there are degrees of compassion, on what are those degrees based? Are there constitutive elements in a compassionate response? Why be compassionate? Must I show compassion toward myself?

Within the sacred Hindu texts one finds discourses that grapple with these questions and provide profound answers.

Buddhism also addresses compassion. The Buddha lived sometime between the 6th and 4th centuries BCE. The words of the Buddha were originally passed via oral tradition, then recorded in the Path of Purification (Visuddhimagga) and other works. The Buddha’s understanding of compassion was as follows:

When there is suffering in others it causes (karoti) good people’s hearts to be moved (kampana), thus it is compassion (karuóá). Or alternatively, it combats (kióáti) others’ suffering, attacks and demolishes it, thus it is compassion. Or alternatively, it is scattered (kiriyati) upon those who suffer, it is extended to them by pervasion, thus it is compassion (karuóá).8

Restated in more modern language: “Compassion is that which makes the heart of the good move at the pain of others. It crushes and destroys the pain of others; thus, it is called compassion. It is called compassion because it shelters and embraces the distressed.”9

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In Buddhist thought, compassion is a virtue. Compassion rises above respect, sympathy, and pity. In compassion we identify with the other and try to understand from her or his point of view. Buddhist scholar William Irwin writes:

Compassion and kindness are virtues that direct us away from ourselves and our craving…. We owe it to ourselves to treat other people with something greater than respect, namely compassion… Compassion involves both the recognition that others are suffering and the fellow-feeling that the recognition brings…. I do not feel sorry for them or have pity for them; I have compassion for them, recognizing their state of being as my own.… Compassion thus involves an ethics of intention. While the carelessness and foolishness of certain actions makes them blameworthy even with good intentions, it is charitable, kind, and appropriate for us to consider others’ intentions. Looking to others with their intentions in mind helps me to cultivate compassion… And on a daily basis, empathic listening requires compassionate intentionalist interpretation. The goal is not to understand the other person as suits me; or from my point of view; or to find some piece of common ground. The goal is to understand the other from his point of view, as he intends and hopes to be understood.10

Note that the questions that underlie Hindu perspectives on compassion are shared in the Buddhist considerations—and those of other religions as well.

Religious discourse on compassion goes beyond the definitional and theoretical to encompass actual “interventions.” Take, for example, the man named Job in the Jewish Tanakh (Bible). The Book of Job dates between the 7th and 4th centuries BCE, with the 6th century as the probable date.11 Job, a righteous man experienced calamity. His children were killed when a wind caused their house to fall in, his sheep and servants were killed in a fire storm, his camels stolen, and Job himself became covered with “loathsome sores… from the sole of his foot to the crown of his head.”12 In addition, he had a nagging wife and friends with a knack for saying exactly the wrong thing. But his friends did get one thing right: they showed compassion.

Now when Job’s three friends heard of all these troubles that had come upon him, each of them set out from his home… They met together to go and console and comfort him. When they saw him from a distance, they did not recognize him, and they raised their voices and wept aloud; they tore their robes and threw dust in the air upon their heads. They sat with him on the ground for seven days and seven nights, and no one spoke a word to him, for they saw that his suffering was very great.13

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In their compassion, Job’s friends engage in presence, a key means of expressing compassion. Presence receives considerable discussion in theological literature, and is a concept and intervention fundamental to nursing and one that nurse scholars have recently begun to explore. However, the Jewish literature also offers insight into hearing another’s lament. It is in expressing, fully expressing, one’s lament—and having that lament heard by another rather than stifled that compassion meets and mitigates suffering. There are, in this ancient literature, specific literary forms or templates for the expression of individual and collective lament. These forms guarantee the full expression of lament and prompt the person to end on a note of hope that they can draw from within.14

These are but three examples. Extensive discussions of compassion are found in all major and most smaller religious traditions. There are also discussions of compassion in the philosophical literature.

Aristotle (384–322 BCE) held that there are five essential social virtues (sing. arête’; pl. aretai): courage, compassion, self-love, friendship, and forgiveness. He sees virtues as larger than moral virtues alone. For Aristotle, moral virtues are aimed at fine and right action. He taught that virtues, as moral aspects of character, can be learned, cultivated, and strengthened. The goal of moral education is to control unruly desires and habits so that desires might be rightly ordered and that virtues might be cultivated. (See Chapter 5 for additional discussion of virtues.) Aristotle distinguished compassion from pity. Pity is condescending and not welcome by its recipient. Compassion, on the other hand, sees the suffering of the other as if it were one’s own suffering. It is possible to have an excess of compassion—softheartedness—as well as a deficiency of compassion as cold-heartedness or callousness. Aristotle ascribes distinctive content to each virtue, including actions, motives, and capacities.15

Aristotle argues that compassion is a painful emotion in response to another person’s suffering or misfortune.16 There are three constitutive elements for compassion: (a) the person’s misfortune or suffering must be of significance, that is, not trivial, (b) the person has no role in causing her or his suffering, i.e., it is undeserved, and (c) an awareness that I, and those whom I love, share in the vulnerabilities and weaknesses of this person and are likewise susceptible to suffering. Martha Nussbaum takes issue with Aristotle’s third condition and maintains that:

in order for compassion to be present, the person must consider the suffering of another as a significant part of his or her own scheme of goals and ends. She must take that person’s ill as affecting her own flourishing. In effect, she must make herself vulnerable in the person of another. It is that eudaimonistic judgment, not the judgment of similar possibilities, that seems to be a necessary constituent of compassion.17

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Eudaimon, often translated as happiness, welfare or even well-being, is more accurately understood as a concept of human flourishing. What Nussbaum is saying is that we all have a concept of what human flourishing looks like and we make a eudaimonistic judgment about persons who are suffering—that they are or are not flourishing—consistent with our understanding of the goals and ends we would seek for our own flourishing. She agrees with Aristotle that we all share in the human condition of susceptibility to suffering, and thus share in a sense of common human community. Where she disagrees with him is that she believes that is it not a judgment of similar possibility of suffering that drives compassion, but rather a judgment about what it takes for me or that person to flourish.

Aristotle is hardly alone in his concern for compassion. Other philosophers have argued about compassion, including the Stoics, Seneca, Schopenhauer, Hume, Hutcheson, Nietzsche, and Kant.

Nurses tend to skim the religious or philosophical literature in their investigations of compassion. Van der Cingel is an exception; she explores selected philosophical works, including those of Aristotle, Schopenhauer, and Nietzsche (largely through Nussbaum’s work). She writes that:

Compassion is an answer to suffering despite the fact that suffering will not disappear by it. Serious suffering can happen to everyone because to suffer is part of human existence. Still, suffering is not always easy to recognize because the meaning of what is lost differs from person to person. In order to recognize the meaning of a loss it is necessary to set aside one’s own perspective. This is troublesome when the relevant perspective is remote from one’s own experience and ideas.… Imagination and reflection…help to develop susceptibility for the other person’s perspective.… Compassion is also defined by the specific thought that suffering is terrible.… Further, compassion is unconditionally valid for everyone suffering.… There is a choice to be made in showing or not showing compassion. To acknowledge suffering by showing compassion means to acknowledge the loss of something valuable, to deny this means adding suffering to suffering that already exists. Therefore, compassion is the morally right thing to express.18

In the empirical portion of her study (with older persons with chronic diseases), she identifies seven dimensions of compassion: attentiveness, active listening, naming of suffering, involvement, helping, being present, and understanding.19 While not identical to the discussions of compassion in the philosophical literature, her findings corroborate a number of the elements that they raise.

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Only a few, including van der Cingel, have drawn rigorously upon the rich religious sources on compassion that are available.20 Those resources continue to develop through theological discourse, and also through such vehicles as the Parliament of the World’s Religions and the Charter for Compassion. In these venues, compassion becomes a social and political force, much like the context of an ethic of care (see Chapter 2) that extends beyond the dyadic nurse– patient relationship. Compassion becomes a social force to address suffering globally by addressing the social determinants of suffering. The text of the Charter for Compassion says, in part:

The principle of compassion lies at the heart of all religious, ethical and spiritual traditions, calling us always to treat all others as we wish to be treated ourselves. Compassion impels us to work tirelessly to alleviate the suffering of our fellow creatures, to dethrone ourselves from the centre of our world and put another there, and to honour the inviolable sanctity of every single human being, treating everybody, without exception, with absolute justice, equity and respect. It is also necessary in both public and private life to refrain consistently and empathically from inflicting pain. To act or speak violently out of spite, chauvinism, or self-interest, to impoverish, exploit or deny basic rights to anybody, and to incite hatred by denigrating others—even our enemies—is a denial of our common humanity. We acknowledge that we have failed to live compassionately and that some have even increased the sum of human misery in the name of religion.21

Note that the Charter for Compassion encompasses many of the facets of compassion addressed by the religious and philosophical traditions noted above, speaking to many of the concerns that nursing shares. The extension of compassion into the larger social and political realm can also be found in these same traditions.

Considering how important compassion is to nursing, it does not appear in the codes to the degree that it should. The successive revisions of the Code err on the side of scientifically skilled nursing, and to some degree have neglected the art of nursing for the science of nursing. This is, in part, a reflection of nursing’s aspirations to be regarded as scientific and as a profession. To some degree, compassion, comfort, and care were assumed and subsumed under rights and patient protection language. In addition, the codes were rightly influenced by shock and outrage at the Nazi experiments exposed after WWII, the disclosures by both Beecher and Pappworth of morally reprobate medical experiments in the United States and UK, the multiple international documents incorporating human rights and self-determination, as well as the rise of bioethics in the mid-1960s emphasizing respect for autonomy. (See Chapter 7 for additional discussion.) These influences lead to a resolute affirmation of rights, self-

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determination, respect for autonomy, and the like in the successive iterations of the Code. This content displaces the interpersonal art of nursing concerns that remain at the heart of nursing care and are encompassed in part in the developing ethic of care. (See Chapter 3). Though compassion is not mentioned specifically, the Tentative Code (1940) does state that the nurse is a “bearer of comfort,” “a source of strength and comfort,” and that “honesty, understanding, gentleness, and patience should characterize all of the acts of the nurse. A sense of the fitness of things is particularly important.”22 Compassion appears in the 2001 revision of the Code: “Provision 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”23

The 2015 revision of the Code retains the concern for compassion and continues to assert it in the actual provision itself: “Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”24

Compassion is inextricably linked to valuing the other, whether the other is another human being, other sentient life, or the environment. This valuing calls for a response of respect in the case of human life, and more specifically those lives that come into contact with nurses, respect for human dignity.

1.1 Respect for Human Dignity

Human dignity first appears in the 1960 Code for Professional Nurses, and in every successive revision thereafter. This is, again, reflective of the international concern for the protection of human dignity. There are some subtle shifts in language as the “dignity of man” (1968 Code) subsequently becomes “human dignity.” The concern for human dignity shifts from the second to the first provision after 1960. Through 1985, the emphasis is on affirming and preserving human dignity in patient care. From the 2001 revision forward, the Code emphasizes affirming and preserving the human dignity of all those with whom nurses have contact, in all nursing roles and settings. This would include the preservation of the human dignity of patients, clients, participants in research, nursing students, co-workers, other health professionals, and colleagues—in short, everyone, including ourselves!

The requirement to respect, affirm, protect, and preserve human dignity still does not explain or define the concept of human dignity. When the concept of human dignity was introduced through the 1948 UN Universal Declaration of Human Rights no attempt was made to define human dignity.25 Düwell notes

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that when human dignity was introduced, it was intended to serve as a moral reference point and that:

Most people believed that they knew what human dignity was about: a consensus within the humanistic tradition, a secularized version of the Judeo-Christian concept of Imago Dei [humankind made in the image of God], an overlap between the ethical doctrines of important thinkers like Kant and Confucius, the normative core of the natural law tradition, a moral-political statement against the atrocities of the Nazi régime, etc.…it thus appeared superfluous to strive for a theoretical explanation and justification of the concept.26

Sulmasy identifies three different uses of dignity in moral discourse: attributed, intrinsic, and inflorescent.27 Attributed dignity refers to worthiness conferred upon a person based on one’s social standing, reputation, or civic office; it is based on merit in a social or public sense. Intrinsic dignity, based in Immanuel Kant’s formulation, is:

that worth or value that people have simply because they are human, not by virtue of any social standing, ability to evoke admiration, or any particular set of talents, skills, or powers. Intrinsic dignity is the value that human beings have simply by virtue of the fact that they are human beings. Thus we say that racism is an offense against human dignity. Used this way, dignity designates a value not conferred or created by human choices, individual or collective, but is prior to human attribution. Kant’s notion of dignity is intrinsic.28

This is the sense in which this Code and all prior codes use the term dignity. Inflorescent is an odd term, as it refers to a flower coming into bloom. Inflorescent dignity, for Sulmasy, refers to the person who is coming into the “full bloom” of virtuous humanity:

to individuals who are flourishing as human beings—living lives that are consistent with and expressive of the intrinsic dignity of the human. Thus, dignity is sometimes used to refer to a state of virtue—a state of affairs in which a human being habitually acts in ways that expresses the intrinsic value of the human. We say, for instance, that so-and-so faced a particularly trying situation with dignity.29

Inflorescent dignity is seen in the caring, compassionate, skilled nurse who brings genuine comfort to the anxious patient; in the researcher who diligently and rigorously pursues a line of inquiry with integrity, skill, perseverance, and a best effort; and in the nursing educator who seeks to advance the knowledge of both the strongest and weakest students with rigor, compassion, wisdom, and devotion to their learning. We can also see inflorescent dignity in the legend of Florence Nightingale, the attributed founder of modern nursing.

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Düwell identifies five models of the term dignity that correlate with Sulmasy’s three forms. Düwell’s particular concern is to identify that form of dignity that will undergird human rights. Of the five models—rank, virtue and duty, dignity and religious status, the cosmological status of the human being, and respect for the dignity of the individual human being—he identifies respect for the dignity of the individual human being as best suited to the task of undergirding human rights, with direct links to the moral and political dimensions of life:30

the specific idea can be distinguished that each single human individual would have dignity. In this line, human dignity should be seen as an expression that signifies a status which other human beings and political institutions have to respect. This respect can be interpreted primarily in a sense of moral obligations or – as happened in the twentieth century – in the sense of individual rights that can be legally enforced. And since this respect is of immanent importance from a moral point of view, it can be seen as a reason to understand the entire legal and political state and international order as based on the respect for the dignity and rights of each individual human being. This concept of ‘human dignity’…is universal; it signifies a status that cannot be lost, and thus may provide a foundation of rights.31

This perspective on human dignity is that which is found in the nursing ethical literature: that human dignity has three distinct features: it is inherent (i.e., it is essential and permanent as it inheres, or “sticks” and is “fixed”), intrinsic (i.e., it is “situated within”; “inner,” and naturally belonging), and inviolable (i.e., it may not be violated).32

However, Macklin has maintained that bioethics has no need for the concept of human dignity, that “dignity is a useless concept in medical ethics and can be eliminated without any loss of content.”33,34 While she uses the principles of respect for persons and respect for autonomy interchangeably, she argues that the principle of respect for persons or respect for autonomy will suffice without the concept of human dignity. Nursing, and particularly an ethic of care (see Chapter 2), would challenge Macklin on this point and would agree with Schulman, who notes that:

in locating human dignity entirely in rational autonomy, Kant was forced to deny any moral significance to other aspects of our humanity, including our family life, our loves, loyalties, and other emotions, as well as our way of coming into the world and all other merely biological facts about the human organism. His exclusive focus on rational autonomy leaves Kant with a rather narrow and constricted account of our moral life.35

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In its embrace of the concept of human dignity, nursing would maintain that respect for autonomy does not exhaust the full meaning of human dignity, that human dignity is an essential moral concept and ground for respect, protection, human rights, and caring.

1.2 Relationships with Patients

Nurses must not, must never, behave prejudicially. In one way or another, this has been a part of all nursing codes, unadopted and adopted. However, reflective of what might be called ever-dawning social awareness, the list of potential sources for prejudice has been an ever-growing list. What began as a proscription against prejudice on the basis of race, creed, and nationality eventually expanded to include religious beliefs, color, status, country, ethnic identification, beliefs, living conditions, customs, attitudes, economic status, culture, life stage, socioeconomic status, personal attributes, nature of the health problem, age, sex, personality, background; political, educational, economic, developmental, personality, role and sexual differences; value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language. There is really no end to the attributes that could be added to the list. The following list demonstrates how the concerns have enlarged across successive revisions of the Code.

1940 “Section 4. A truly professional nurse with broad social vision will have a sympathetic understanding of different creeds, nationalities, and races and in any case you will not permit her personal attitude toward these various groups to interfere with her function as a nurse.”

Section 1. The nurse has a basic concern for people as human beings, confidence in the fundamental power of personality for good, respect for religious beliefs of others, and a philosophy which will sustain and inspire others as well as herself. Failure to possess these qualities means inability to live up to the responsibilities and to make the most of her opportunities.36

1950 “Provision 4. Religious beliefs of the patient must be respected.”37

1960 “Provision 2. The nurse provides services based on human need, with respect for human dignity, unrestricted by considerations of nationality, race, creed, color or status.”38

1968 “Provision 1. The nurse provides services first with respect for the dignity of man, unrestricted by considerations of nationality, race, creed, color, or status.”39

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1976 “Provision 1. The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social economic status, personal attributes, the nature of health problems.”

Interpretive Statement 1.3. Age, sex, race color, personality, or other personal attributes, as well as individual differences in background, customs, attitudes, and beliefs influence nursing practice only insofar as they represent factors the nurse must understand, consider and respect in tailoring care to personal needs and in maintaining the individual value systems and life-styles should be included in the planning of health care for each client.40

1985 “Provision 1. The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”

Interpretive Statement: 1.2. The need for health care is universal, transcending all national, ethnic, racial, religious, cultural, political, educational, economic, developmental, personality, role and sexual differences. Nursing care is delivered without prejudicial behavior.41

2001 “Provision 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”

“Interpretive Statement 1.2 The need for health care is universal, transcending all individual differences.”42

2015 “Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”

Interpretive Statement 1.2: Relationships with Patients. Nurses establish relationships of trust and provide nursing services according to need, setting aside any bias or prejudice. Factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language are to be considered when planning individual, family and population- centered care. Such considerations must promote health and wellness, address problems, and respect patients’ or clients’ decisions. Respect for patient decisions does not require that the nurse agree with or support all patient choices. When patient choices are risky or self- destructive, nurses have an obligation to address the behavior and to offer opportunities and resources to modify the behavior or to eradicate the risk.43

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In an attempt to constrain infinitely expansible lists in the Code, the committee working to revise the 1985 Code made the decision to write using categories where possible. The committee to revise the 2001 Code consciously sought to do the same.

It is important to take specific note of the dates of these provisions. They are evidence that in many instances nursing was significantly ahead of society in its demand for respect for persons regardless of their personal attributes. In particular, nursing’s ethical concern and actions on behalf of and for persons of color was decades ahead of the civil rights movement. The directives are resolute and crystal clear: patient personal attributes, circumstances, or life choices are never grounds for prejudice and may be used only to individualize care in accord with patient needs. Nurses are expected to have a “broad social vision,” that is a tolerance, or better, to be welcoming of human differences, and to affirm human dignity whatever those differences. Prejudice is never acceptable and where present must be set aside.

What is prejudice? It is a harmful or damaging opinion of another person or a class of persons that is rooted in bias, preference, preconception, antagonism, or unreasoned dislike.44 Discrimination is different in that it differentiates between and among persons on the basis of relevant differences (e.g., age- based drinking, driving, voting, and marriage requirements) and should not be confused with prejudice which is a form of unjust discrimination. Prejudice can occur at individual or societal (structural) levels, and include processes of othering (regarding another person or group as alien, as different from the norm),45 marginalization, silencing their voice, essentializing, racializing, classing, subordinating, and more.46 These processes are challenged by a wide range of feminist, postcolonial, and critical theories.

Patient care decisions are rightly affected by all of those attributes listed above, not to be used prejudicially, but in order to provide care that is individualized based on those attributes. In relationships with patients, nurses respect patient decisions, but:

respect for patient decisions does not require that the nurse agree with or support all patient choices. When patient choices are risky or self-destructive, nurses have an obligation to address the behavior and to offer opportunities and resources to modify the behavior or to eradicate the risk.47

The focus of this brief interpretative statement is upon patient attributes and factors that could potentially provoke a nurse’s prejudice(s) and negatively influence nursing care. The second provision includes a section on the primacy of the patient’s interests and speaks further to the nurse–patient relationship. (An ethic of care is discussed under Interpretive Statement 2.1.)

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1.3 The Nature of Health

The nurse’s responsibility regarding health has expanded over the last 150 years. Initially the focus was upon the health of the patient and those about the patient and the health of the public. It is important to note that from the start of modern nursing in the United States in the 1870s, nurses were directed toward both the health of the patient and the health of the public. Eventually, in 2001, this obligation came to encompass the promotion and access to health nationally, internationally, and globally, as well as the development of health policy and health diplomacy, and the ablation of health disparities worldwide. The progression of these obligations can be seen in provisions of each of the successive codes. Selected examples include the following:

1926 “the mutuality of aim of medicine and nursing; the aims, to cure and prevent disease and promote positive health,” and “the health of the public…building positive health in the community.”48

1940 Her role as a bearer of comfort and health to the sick, the injured, and the feeble, dates from the early days of Christianity, but in the modern conception of nursing the prevention of disease and the promotion of health are at least as important…as the care and treatment of the sick. Indeed, these functions cannot be separated although they are undoubtedly represented in different proportions in the different fields of nursing. Moreover, the nurse is essentially a teacher and an agent of health in whatever field she may be working.

“she will welcome and utilize opportunities to offer suggestions and help for the health protection of the individual, the family, and the community.”49

1976 and 1985 “Provision 11: The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.”50,51

2001 “Provision 8: The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.”52

2015 “Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.”53

In the late 1960s, the Code still emphasizes both the health of the patient and the public (at times identified as “citizens”), but by 1976 it comes to include national health needs. The transition point in the expansion of the

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understanding of influences upon health is in the 2001 Code. Provision 8.1 becomes a major expansion of nursing’s scope of concern for health:

The nursing profession is committed to promoting the health, welfare, and safety of all people. The nurse has a responsibility to be award of not only health needs of individual patients but also of broader health concerns such as world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of nursing and healthcare resources. 54

Through 1985, the word citizens is used—nurses were to collaborate with other health professions and citizens to promote health. With an increased public awareness of the health needs of non-citizen immigrants, especially those persons who immigrated without documents, the term citizens is dropped from the Code.

Between 1985 and 2001, global interactions escalated through technological means and the globe began to shrink. The current Ebola crisis in 2014 made US residents acutely aware of global health and the danger of contagion and pandemic. The health of the public must move from citizens to all residents of the nation, and from an insular regional or national concern to global concern.

Nursing, in part through its historic concern for public health and the social determinants of illness, has increased its civic engagement and civic professionalism decade by decade. This is reflected in the 2001 Code in its concern for nursing organizations:

to speak collectively for nurses in shaping and reshaping health care within our nation, specifically in areas of healthcare policy and legislation…. In these activities health is understood as being broader than delivery and reimbursement systems, but extending to health-related sociocultural issues such as violation of human rights, homelessness, hunger, violence and the stigma of illness.55

Civic engagement refers to taking the values and ideals of nursing into political life. While technical professionalism focuses on the acquisition, mastery, and implementation of the technical knowledge and skills of nursing in the delivery of patient care, civic professionalism sets nursing and nursing care within the broader moral and political context that shapes health and health care. (See also Chapter 2 on an ethic of care that sets care within the broader social, moral, and political context.) Boyte and Fretz write of the task of civic engagement as engendering “civic professionals who will renew a robust sense of the public purposes of their work and will develop and sustain a far more public culture for collaborative, visible, open work.”56 Nursing has never lost the “robust sense of public purpose of [its] work.” However, the 2015 Code amplifies that role in

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several ways, calling nurses to engagement that serves the common good, seeks social justice, raises international health diplomacy to parity with economic and other concerns, leads collaborative efforts for health policy and legislation that positively impacts health, protects human rights, and address the structural, social, and institutional inequalities and disparities that are damaging to health and well-being.57 While every nurse is called upon to contribute, no one nurse can meet this obligation alone. Civic engagement through civic professionalism requires collaborative and united efforts among nurses and with other health professions, activists, and organizations.

1.4 The Right to Self-Determination

The right to self-determination does not appear in the Code until 1968, at which point it refers to the patient’s right to self-determination as a participant in research. From 1976 forward, with the rise of the field of bioethics, however, the patient’s right to self-determination receives considerable emphasis in the first provision and interpretive statements, from the 1976 to 2015 Codes. 58,59,60

While the content of these provisions is essentially the same, they become more precise over the years. In addition, unlike the 1976 provision and inferentially in the 1985 provision, the 2001 Code explicitly roots self- determination in human dignity, as does the 2015 Code.

The bioethical principle that generates the duty to respect patient self- determination is the principle of respect for autonomy. It is one of the four principles commonly used in bioethics discussions and on institutional ethics committees: respect for autonomy, nonmaleficence, beneficence (sometimes combined with nonmaleficence), and justice. Principles are used to specify our moral duties and aid in ethical analysis and decision-making. The principle of respect for autonomy specifies that we have an ethical duty to respect the autonomous decisions of others. The principle is best explicated in the work of Beauchamp and Childress, Principles of Biomedical Ethics,61 and more briefly in The Belmont Report.62 Both works largely follow Kant’s interpretation of autonomy and the need to respect it.

In Kant, autonomy is rational self-legislation (self-rule), which describes persons who make rational choices free of non-rational internal constraints or influences (such as habit, compulsion, depression, mental illness, inebriation) and also free of non-rational external constraints (such as duress, fraud, coercion, undue influence). Autonomous choices are intentional, rational, and free. The autonomous person acts freely in accord with her or his own values and a self-chosen plan. At times one may rationally choose to not to affirm one’s own values, and it remains an autonomous decision nonetheless.

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For example, a person may refuse medical treatment necessary to sustain life because of the financial burden it would impose. In the context of ethics, even children can make autonomous choices (though the law does not necessarily honor those choices). Autonomy may also fluctuate, as in a person with Alzheimer’s disease who has good days and bad days. In addition, persons who are generally autonomous may not always be autonomous. An acute knee injury involving a degree of severe pain may render the athlete non- autonomous. Assessments of autonomy need to be made in the moment.

The principle of respect for autonomy specifies our duty to respect the autonomous choices of others. It is important to note that the principle is not a principle of autonomy. It is the principle of respect for autonomy. There is no principle of autonomy; autonomy by itself is not a principle. Often when it is listed as a principle, look carefully and you will see “respect for” in the nearby text. Recall that principles specify duties. If autonomy itself were a principle, it would mean that each of us has a duty to act autonomously. We are not, however, obligated to act autonomously. Many of life’s choices are made non- autonomously, whether by habit, compulsion, coercion, or simply without rational consideration. We do things we would rather not because we have been asked by a friend; we choose on the basis of taste, color, preference, or habit; we go into ‘auto-pilot mode’ when tired; we succumb to peer pressure and “go with the flow” when we would rather not; we eat the whole batch of snickerdoodle cookies before we realize that the plate is empty. Where healthcare decisions are required, however, we want patients to make free, intentional, autonomous decisions, and we are called upon to respect them.

For patient decisions to be autonomous, two conditions must be met. Patients need adequate and accurate information and their decisions need to be voluntary. In clinical practice these two conditions are actualized through the process of informed consent. Informedness requires that the patient or research participant have all the materially relevant information necessary to make a decision in accord with her or his values, situation, and context. Voluntariness specifies the need to be free of controlling influences, whether internal or external.

The emphasis upon respect for autonomy, informed consent, and voluntariness emerged, in large part, as a response to the Nazi medical atrocities of WWII. These came to light in 1947, at the trial of 27 Nazi physicians.63 In the aftermath of the discoveries of the horrific, often lethal, experiments that were conducted on non-consenting human prisoners, a number of international documents were ratified that enshrined the legal and moral requirement to protect persons who might become research participants by requiring consent. 64 These documents include The Nuremberg Code,65 the 1949 World Medical Association (WMA) Declaration of Geneva,66 and the

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WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects,67 and later documents such as The Belmont Report noted above. It is important to note that nurses were complicit in the medical killings in Nazi Germany, both in euthanizing persons and in the conduct of medical experimentation on unwilling prisoners.68,69,70,71

Because valid informed consent requires voluntariness, in situations where the person is nonvoluntary and thereby unable to make a decision by reason of her or his situation (e.g., in a coma, too young, too ill, inebriated, etc.), decisions are to be made in the best interests of the patient and may be made by a surrogate decision-maker. Interpretive Statement 1.4 includes legal surrogates in the informed consent process. A surrogate is someone who acts on behalf of another when that person cannot act on his or her own behalf. Surrogates are needed for persons whose condition or status does not allow them to participate, such as a person who is unconscious, an infant, or a person with severe intellectual compromise. A surrogate might be appointed by a court or might be designated by a patient through an advance directive. The duty of a surrogate is to make the decision on behalf of the person or patient that they themselves would have made if they were able to do so, or if the person’s wishes could not be ascertained, to make the decision in the best interests of the person or patient.

At times, a court may appoint a surrogate, in which case the surrogate may or may not know the patient. In the situation of a formerly autonomous patient whose surrogate knows the patient, the substituted judgment standard is used. That means that the surrogate stands in for the patient and makes a decision that the patient would have made were he or she able to do so. That is, the surrogate should base the decision on the known views, values, and desires of the patient. Where the surrogate does not know what the patient would have wanted, and those wishes cannot be known through other means (e.g., they were put in writing), or where the patient was never autonomous, then the surrogate must make the decision that is in the best interests of the patient. In neither case does the surrogate make the decision based on the surrogate’s own preferences and desires. Beauchamp and Childress note that “the best interests standard protects an incompetent person’s welfare interests by requiring surrogates to assess the risks and probable benefits of various treatments and alternatives to treatment. It is therefore inescapably a quality-of-life criterion.”72

Autonomous decisions do not have to be made solely by the individual patient alone. Autonomous decisions may be made by a patient with family members, or the patient within her or his community of reference. This may reflect a cultural pattern or may simply reflect a patient’s preferences and commitments.

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At times, an overweening commitment to respecting patient autonomy has lead health professionals to refuse to advise patients. This goes too far. Respect for patient autonomy does not mean that health professionals may not offer a professional opinion or advice. It does mean that such advice should be offered truthfully and noncoercively. In the 2015 Code, nursing bases its commitment to respect for autonomy in human dignity. Nurses offer information and advice to patients in ways that exercise compassion, affirm patient dignity, and recognize the uniqueness of the patient as a person.

1.5 Relationships with Colleagues and Others

The content of this interpretive statement introduces several themes to be repeated throughout the 2015 revision. Some would argue the content more properly belongs under Provision 6, and in fact some of the concepts of this section are elaborated under Provision 6. However, this brief section on relationships with colleagues is placed here to emphasize that this provision—“The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person”—is meant to be applied everyone, not only to patients. Some of the themes are ethical environment, caring relationships, fair treatment, and conflict resolution. This interpretive statement also introduces the explicit intent of the Code to include all nurses, in all roles and all settings. It also recognizes the excellent contributions of others who work alongside nurses to achieve safe, effective, quality outcomes everywhere they work.

Lateral violence or bullying (or mobbing) in the workplace is denounced by the following quote: “[T]he nurse creates an ethical environment, a culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect. This standard of conduct includes an affirmative duty to act to prevent harm.”73 This includes all nursing relationships with colleagues, administrators, educators, researchers—in short—,with everyone. That nurses have an affirmative duty is clearly articulated. This duty goes beyond not participating in harassment or intimidation; nurses must be proactive; they must to act to prevent harm. The hallmarks of these relationships are respect, caring, fairness, transparency, integrity, civility, kindness, dignity, respect, and collaboration. This is a relational environment in which all might thrive and flourish.

Cases

The cases in each of the chapters are intended to provide the opportunity to reflect upon the content of the specific provision and interpretive statements. The cases may be used for group discussion or for personal reflection. A list of suggested questions for consideration of the cases is provided in the introduction to the book.

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Case 1

Jean Thatcher is a 47-year-old single white attorney with multiple sclerosis. She is frequently admitted to the transitional care facility for complications related to her multiple sclerosis. Since she quickly exhausts the patience and best efforts of the staff, she is rotated among several units, all of whom know her well and her inpatient stays on their unit are anticipated with fear and trepidation. The staff’s best efforts to educate her about appropriate self-care and preventive practices have fallen on deaf ears. She refuses to cooperate when her support is elicited for bathing, position changes, and the like. Her one visitor, her mother, believes that the staff discriminates against her and complains frequently to administration. Both the patient and her mother frequently threaten to sue the hospital for neglect and discrimination. Jean admits that she is refusing to eat or help with bathing and positioning. She says she has “had enough” and wants to give up. Most of the staff have already given up and ask why they should try to help Jean when she has been clear about not wanting their help. Today, one nurse was overheard saying, “I’m not going to sprain my back trying to get her to move when she refuses to cooperate. It’s on her if her skin breaks down.” The nurse manager calls a meeting to explore how the team might more effectively and compassionately respond to the challenges of caring for Ms Thatcher.

Case 2

Ms Rogers staggers into the emergency room at 2:00 a.m. complaining of abdominal pain. Well-known to the ER staff, she is a homeless Gulf War Veteran, retired US Army Sergeant, and has a history of alcoholism and PTSD. There are too few homeless shelters for women and those few are currently full. She does not go to the VA hospital to receive care as it is 22 miles away and she has no transportation. The night is cold and there is freezing rain. The resident called to examine Ms Rogers does not “work-up” the complaint of belly pain, instead saying that, once again, Ms Rogers only wants a warm bed for the night, a bath, and something to eat.

Case 3

Victoria Oliver is the dean of a small nursing school, respected for the excellence of its programs. The school is successful and has a welcoming and collegial environment and because of this, low faculty turnover. However, health problems have brought about the resignation of one of the pediatric nursing faculty. Multiple candidates have applied but two have risen to the top. Both are highly qualified with excellent backgrounds in teaching, research, publications, and professional engagement. Candidate #1 has slightly more experience. The faculty search committee has come to a draw

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and has recommended both candidates to the dean, who must now choose one of them. Candidate #1 is from a well-known and prestigious university, and Candidate #2 is from a small, well-regarded school similar in size to the Dean’s school. Prior to interviewing the candidates, it is brought to Dean Oliver’s attention that Candidate #1 has posted to her social media page that her father has macular degeneration. In addition, that candidate has also posted information that displays an extreme political bent. The faculty member who brought this information to the Dean’s attention is a friend of Candidate #2.

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ENDNOTES

All URLs were current when accessed on January 9, 2015. 1 Oxford English Dictionary Online, “Compassion,” http://0www.oed.com.patris.apu.edu/view/

Entry/37475?isAdvanced=false&result=1&rskey=bl0Sx2& 2 Oxford English Dictionary Online, “Patient,” http://0www.oed.com.patris.apu.edu/view/

Entry/138820?result=1&rskey=fhetaF& 3 Joseph Kitigawa (ed.), The Religious Traditions of Asia: Religion, History, and Culture (New York:

Routledge, 2013). 4 Alf Hiltebeitel, “Hinduism,” in The Religious Traditions of Asia: Religion, History, and Culture, ed.

Joseph Kitigawa (New York: Routledge, 2013), 120–121. 5 BC (Before Christ) and AD (Anno Domini; In the Year of Our Lord) is a system of dating that

uses the life of Jesus of Nazareth as the referent. It is customary in academic circles to use the designation BCE (Before the Common Era) and CE (in the Common Era) in place of BC and AD. The year designations otherwise remain the same.

6 SpokenSanskrit, “Compassion,” http://spokensanskrit.de/index. php?tinput=compassion&direction=ES&script=HK&link=yes&beginning=0

7 Kutumba Sastry, “Compassion: Etymology, Rituals, Anecdotes from the Hindu Tradition,” in Compassion in the World’s Religions: Envisioning Human Solidarity, eds. Anindita Balslev and Dirk Evers (Münster, Germany: Lit Verlag, 2010), 43–44.

8 Bhikkhu –Ñáóamoli, trans., Bhadantácariya Buddhaghosa’s Visuddhimagga, 3rd online edition. Translated from the Pali by Bhikkhu –Ñáóamoli, 2011, 311.

9 Chinese Buddhist Encyclopedia, “Karuṇā,” http://www.chinabuddhismencyclopedia.com/en/ index.php?title=Karuṇā

10 William Irwin, “Liberation through Compassion and Kindness: the Buddhist Eightfold Path as Philosophy of Life,” Journal of Philosophy of Life 3, no. 1 (January 2013): 69–70.

11 Robert Kugler and Patrick Hartin, An Introduction to the Bible (Grand Rapids, MI: WB Eerdmans, 2009), 193.

12 Bruce Metzger and Roland Murphy (eds.), The New Oxford Annotated Bible with Apocryphal/ Deuterocanonical Books: New Revised Standard Version (NY: Oxford University Press, 1994), 626OT.

13 Ibid. 14 Marsha Fowler, “Come; Give Me a Taste of Shalom,” in Nursing and Health Care Ethics: A Legacy

and a Vision, eds. W. Pinch and A. Haddad (Silver Spring, MD: ANA Publishing, 2008), 269–81. 15 Aristotle, Nichomachean Ethics, Book III, trans. Martin Ostwald (Indianapolis, IN: Bobbs-Merrill,

1962), 33–51. 16 Aristotle. Rhetoric (Book 1), trans. W. Rhys Roberts (Mineola, NY: Dover Publications, 2004)

Chapter 7, section 1385b. 17 Martha C. Nussbaum, Upheavals of Thought: The Intelligence of Emotions (Cambridge, UK:

Cambridge University Press, 2001), 319. 18 Margreet van der Cingel, “Compassion and Professional Care: Exploring the Domain,” Nursing

Philosophy 10, no. 2 (April 2009): 134–35. 19 Margreet van der Cingel, “Compassion: The Missing Link in Quality of Care,” Nurse Education

Today 34, no. 9 (September 2014): 1255. 20 See for example: Collette Straughair, “Exploring compassion: Implications for contemporary

nursing, P. 1,” British Journal of Nursing 21, no. 3 (February 2012): 160–64.

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21 The full text of the Charter for Compassion is available at this webpage: http:// charterforcompassion.org/charter

22 American Nurses Association, “A Tentative Code,” American Journal of Nursing 40, no. 9 (1940): 977–80.

23 American Nurses Association, Code of Ethics for Nurses with Interpretive Statements (Silver Spring, MD: ANA, 2001), 11.

24 American Nurses Association, Code of Ethics for Nurses with Interpretive Statements (Silver Spring, MD: ANA, 2015), 1.

25 United Nations, Universal Declaration of Human Rights (General Assembly, 1948), http://www. un.org/en/documents/udhr/

26 Marcus Düwell, “Human Dignity: Concepts, Discussions, Philosophical Perspectives,” in The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives, eds. Marcus Düwell, Jens Braarvig, Roger Brownsword, and Dietmar Mieth (Cambridge, UK: Cambridge University Press, 2014), 23.

27 Daniel Sulmasy, “Dignity and Bioethics: History, Theory, and Selected Applications,” in President’s Council on Bioethics, Human Dignity and Bioethics (Washington, DC: USGPO, March 2008), 493.

28 Ibid. 29 Ibid. 30 Düwell, “Human Dignity,” 25–27. 31 Ibid., 27. 32 Oxford English Dictionary Online, “Inviolable,” http://0-www.oed.com.patris.apu.edu/view/

Entry/99105?redirectedFrom=inviolable& 33 Ruth Macklin, “Dignity is a Useless Concept,” British Medical Journal 327, no. 7429 (December

2003): 1419–20. 34 Ruth Macklin, “Reflections on the Human Dignity Symposium: Is Dignity a Useless Concept?”

Journal of Palliative Care 20, no. 3 (Autumn 2004): 121–26. 35 Adam Schulman, “Bioethics and the Question of Human Dignity,” in President’s Council on

Bioethics, Human Dignity and Bioethics (Washington, DC: USGPO, March 2008), 11. 36 ANA, Tentative Code, 978. 37 American Nurses Association, A Code for Professional Nurses (NY: ANA, 1950). 38 American Nurses Association, Interpretation of the Statements of the Code for Professional Nurses

(New York: ANA, 1960), 6. 39 ANA. A Code for Professional Nurses. (New York: ANA, 1968), 3. 40 ANA, Code of Ethics for Nurses with Interpretive Statements (Kansas City, MO: ANA, 1976), 4. 41 ANA, Code of Ethics for Nurses with Interpretive Statements (Kansas City, MO: ANA, 1985), 3. 42 ANA, Code of Ethics for Nurses with Interpretive Statements(2001). 43 ANA, Code of Ethics for Nurses with Interpretive Statements(2015), 1. 44 Oxford English Dictionary Online. “Prejudice,” http://0-www.oed.com.patris.apu.edu/view/

Entry/150162?rskey=IfkR4q&result=1#eid 45 Edward W. Saïd, Orientalism (25th Anniversary Edition) (New York: Pantheon Books, 1978). 46 Sheryl Reimer-Kirkham and Joan Anderson, “Postcolonial Nursing Scholarship: From

Epistemology to Method,” Advances in Nursing Science 25, no. 1 (2002): 1–17. 47 ANA, Code of Ethics for Nurses with Interpretive Statements (2015), 1. 48 American Nurses Association, “A Suggested Code,” American Journal of Nursing 26, no. 8

(August 1926): 599–601.

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49 ANA, “Tentative Code.” 50 ANA, Code of Ethics for Nurses with Interpretive Statements(1976), 19. 51 ANA, Code of Ethics for Nurses with Interpretive Statements(1985), 16. 52 ANA, Code of Ethics for Nurses with Interpretive Statements(2001), 29. 53 ANA, Code of Ethics for Nurses with Interpretive Statements(2015), 31. 54 ANA, Code of Ethics for Nurses with Interpretive Statements(2001), 28–29. 55 Ibid., 31. 56 Harry Boyte and Eric Fretz, “Civic Professionalism,” Journal of Higher Education Outreach and

Engagement 14, no. 2 (2010): 69. 57 ANA, Code of Ethics for Nurses with Interpretive Statements(2015), 32. 58 ANA, Code of Ethics for Nurses with Interpretive Statements(1976), 4. 59 ANA, Code of Ethics for Nurses with Interpretive Statements(1985), 2. 60 ANA, Code of Ethics for Nurses with Interpretive Statements(2001), 12–13. 61 Tom Beauchamp and James Childress, Principles of Biomedical Ethics (7th ed.) (New York: Oxford

University Press, 2013). 62 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral

Research of the U.S. Department of Health and Human Services, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research (Washington, D.C.: DHHS/USGPO, 1979) , available at http://www.hhs.gov/ohrp/humansubjects/guidance/ belmont.html

63 George J. Annas and Michael A. Grodin, The Nazi Doctors and the Nuremberg Code (New York: Oxford University Press, 1992).

64 Robert Jay Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986).

65 “The Nuremberg Code,” Department of Health and Human Services, http://www.hhs.gov/ohrp/ archive/nurcode.html

66 World Medical Association, Declaration of Geneva(1949), available at http://www.wma.net/ en/30publications/10policies/g1/

67 World Medical Association, Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects (Helsinki, Finland: General Assembly, 1964), http://www.wma.net/ en/30publications/10policies/b3/

68 Thomas Froth, “Nurses, medical records and the killing of sick persons before, during, and after the Nazi regime in Germany,” Nursing Inquiry 20, no. 2 (2013): 92–100. See also: Thomas Froth, “Understanding ‘Caring’ through Biopolitics: The Case of Nurses under the Nazi Regime,” Nursing Philosophy 14, no. 4 (2013): 284–94.

69 Susan Benedict, Arthur Caplan, and Traute Lafrenz Page, “Duty and ‘Euthanasia’: The Nurses of Meseritz-Obrawalde,” Nursing Ethics 14, no. 6 (2007): 781–94.

70 Andrew McKie, “‘The Demolition of a Man’: Lessons from Holocaust Literature for the Teaching of Nursing Ethics,” Nursing Ethics 11, no. 2 (2004): 138–49.

71 Mary Lagerwey, “Nursing Ethics at Hadamar,” Qualitative Health Research 9, no. 6 (November 1999): 759–72.

72 Beauchamp and Childress, Principles of Biomedical Ethics, 228–29. 73 ANA, Code of Ethics for Nurses with Interpretive Statements(2015), 4.

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Provision 2. The Patient as Nursing’s Foundational Commitment

Introduction

Even though this commitment is present in the nursing literature from the earliest days, it first appears as a provision in the 2001 Code. This provision addresses the question “What is the nature of the relationship that the nurse has with a patient?” It is a relationship that is both complicated and simple. It is complicated in that frequently the nurse is an employee and there is an employer expectation of loyalty. But the nurse is also caring for a patient, and the nurse–patient relationship, the primary relationship, is also one that creates loyalty. This creates a situation of dual or competing loyalties for the nurse. Competing loyalties arise when the nurse has allegiances or commitments, with attendant obligations, to separate entities that may come into conflict with one another. Competing loyalties occur in a wide variety of situations: the nurse involved in clinical care on a research unit, or serving in a hurricane when their own family might be in danger, or called upon to give care to an enemy combatant, assigned to force feed prisoners, or asked to place an intravenous line for the lethal injection of a criminal. All persons hold multiple, potentially conflicting, loyalties. Ronald Corwin, who examines the role conflict that arises when professional nursing values and ideals come into conflict with bureaucratic (employer) values, maintains that nurses must have some loyalty to patients, some loyalty to the employer, and some loyalty to the profession, and that it is the relative weight and priority accorded to each of those loyalties that is the ground for potential conflict.1 (See Provision 6 on moral distress.)

Loyalty has been under-researched by nursing. Much of the research that has been done relates loyalty, without defining it, to employer and nurse satisfaction, employee retention, or to nurses remaining in nursing. What loyalty is, as a concept, is not explored. It is necessary to turn to the

Provision 2 The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

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philosophical literature for a conceptual analysis of loyalty, particularly its relationship to ethics. Oldenquist maintains that loyalties are “self-dependent normative judgments,” that is:

When I have a loyalty toward something I have somehow come to view it as mine…I am disposed to feel pride when it prospers, shame when it declines, and anger or indignation when it is harmed. In general, people care about the objects of their loyalties, and they acknowledge obligations that they would not acknowledge were it not for their loyalties. Unlike the object of self-interest, an object of loyalty can be shared or “owned” by a number of people. In this case I (and others) can speak of our family, community, country, etc. and not just of my family.2

So loyalty arises because this is my school of nursing, my hospital, my community, my profession—and it is also our school, our hospital, our community, and our profession, as a shared loyalty. But is loyalty a specifically moral norm?

Loyalty is not self-interested, because people can sacrifice, in the name of loyalty, their happiness and even their lives, and it probably is this element of potential self-sacrifice that makes most people classify motives of loyalty as moral motives…loyalty is positive and is primarily characterized by esteem and concern for the common good of one’s group.3

Oldenquist holds that loyalty is the basis for social morality, for shared morality, and for acts that further the common good. He also makes an additional point that is worthy of note: loyalty can be lost when the object of loyalty is no longer worthy of loyalty.4

The Nightingale Pledge carries a two-fold loyalty: “With loyalty will endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care.”5

2.1 Primacy of the Patient’s Interests

Because the nurse’s primary commitment is to the patient, it carries the greatest weight and priority and consequently it trumps all other loyalties. As Corwin notes, it is the relative weight and priority accorded to each of those loyalties that is the ground for potential conflict.6 Realistically, it supersedes all other loyalties within the professional sphere, but perhaps not in the personal sphere if the welfare of one’s family is at stake—not inconvenience to the family, but its actual welfare.

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Loyalty is not the whole of the relationship, for the nurse–patient relationship is much larger than loyalty. Many have captured the nature of that relationship as situated within an “ethic of care.”7 Of the various approaches to ethics, such as ethical principlism (see Chapter 3), or virtue ethics (see Chapter 5), an ethic of care has gained a degree of prominence in nursing that it has not yet achieved in other disciplines. While it is not itself a feminist theory of ethics, it has roots in feminism. Care ethics arose during the Lawrence Kohlberg–Carol Gilligan debate of the late 1970s. Kohlberg had developed a hierarchical stage theory of moral development, focusing on cognitive psychological structures, as Jean Piaget had before him. His theory proposed three levels with two stages in each level. The levels and stages of moral development are:

Level 1: Pre-conventional Stage 1. Obedience and punishment orientation (avoidance of punishment) Stage 2. Self-interest orientation

Level 2: Conventional Stage 3. Interpersonal accord and conformity (adherence to social norms) Stage 4. Authority and social-order maintaining orientation (obey the law)

Level 3: Post-Conventional Stage 5. Social contract orientation (acknowledge pluralism; mutuality

of respect) Stage 6. Universal ethical principles (principle based conscience

and reasoning)8

Kohlberg claims that in his final stage, “universal ethical principles,” moral reasoning is based on the use of abstract, universal ethical principles. It is heavily justice-centered in this stage. Based on his research, initially using only male subjects, he claimed that few people reached Stage 6, that women only tended to develop to Stage 3, and that while men employed abstract ethical reasoning at a level beyond that of women, women tended to focus instead on the welfare of family and friends and relationships. Gilligan challenged Kohlberg’s theory and findings as androcentric and as formulating an inadequate account of the moral values and reasoning of women. Gilligan developed an alternate theory of moral reasoning, in three stages, based on an ethic of care that reinterpreted justice from a gendered perspective.9 Subsequent research has shown that care-based versus justice-based approaches to ethics are not gender-based.10

Two streams of work and theory developed, one focused on the art and science of caring in nursing, and the other specifically on an ethic of care (not limited to nursing). The two streams intermingle at points. Those whose work has been foundational and who have furthered the theory of human

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care and caring, with which an ethic of care is associated, include Noddings,11 Tronto,12,13 Baier,14 Benner,15 Held,16 Sevenhuijsen,17 Slote,18 Watson,19 Leininger,20 and Roach.21

A considerable amount of research and theory development, more specifically on an ethic of care, has taken place in Europe.22 For example, the International Care Ethics (ICE) Observatory in Surrey, England (formerly the International Centre for Nursing Ethics) has the following as its overall aim: “The ICE Observatory acts as an inter-disciplinary, national and international hub of educational, organisational and research expertise and activity to revalue care and promote an in-depth understanding of, and commitment to, ethics in health and social care.”23 The ICE Observatory is the home of the first nursing journal devoted entirely to ethics, Nursing Ethics: An International Journal for Health Care Professionals, which began in 1994.

An ethic of care starts with the concept of relationship. This is not simply the nurse–patient relationship but rather the entire relational nexus in which the nurse and patient are situated. This would include the patient and the patient’s family or close relationships. It also includes the nurse, and the healthcare team. Beyond that it includes the institution or agency in which care takes place, for the institution’s policies and ethos will affect care and the ways in which it is given. And looking even farther, beyond that relationship, also includes society and its expectations for what care is and how it should be given. Even our relationships with the natural environment have a place in an ethic of care. Advocates for an ethic of care claim that an ethic of care successfully overcomes the limitations of ethical principlism. In particular, they maintain that ethical principlism sees clinical cases as conflicts or dilemmas and in doing so problematizes clinical ethical decision-making in nursing. Benner et al. assert that:

Nursing students need to learn about critical ethics and dilemma ethics, but also everyday ethical comportment related to relational or care ethics. Students must learn everyday ethical comportment and the notions of good central to the profession. Student nurses need to learn the ethics of care and responsibility, the ethos of self-care in the profession, skills of involvement, and clinical reasoning. Students need to be able to reflect on and articulate their everyday ethical concerns, and not limit their understanding to ethical breakdowns and dilemmas.24

Early development of an ethic of care focused more narrowly on dyads such as mother–child or nurse–patient. Initial theoretical development was somewhat diffuse or vague and failed to specify whether care was a duty, virtue, value (end that was to be sought), emotion, feeling, or trait of personality. Gastmans argues that care is a virtue.25 Virtues are habits of moral character that are learned and habituated and are not personality traits or

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feelings. Virtues predispose a person to do what is right; that is, to meet one’s ethical obligations. See Chapter 5 for a discussion of virtue ethics. There was also a tendency to identify an ethic of care as intrinsically gendered.

Tronto’s masterful work, Moral Boundaries: A Political Argument for an Ethics of Care, sets forth a theory of care that tackles some of the lingering and nagging concerns with prior formulations.26 She, with Fisher, define care in this way:

On the most general level, we suggest that caring be viewed as a species activity that includes everything that we do to maintain, continue, and repair our ‘world’ so that we can live in it as well as possible. That world incudes our bodies, our selves, and our environment, all of which we seek to interweave in a complex, life-sustaining web.27

Tronto explicitly rejects what has come to dominate bioethical discourse: a set of universal, impartial, value neutral, ethical principles that form the basis for moral reasoning, decision making, and action. She writes:

[Philosopher Immanuel] Kant’s notion of ethical life set…the boundaries around morality as an autonomous sphere of human life. These boundaries require that morality be derived from human reason in the form of universal principles that are abstract and formal. They require that the social and political connections to morality not be counted as central to morality itself.… And they require that…morality consists of a set of principles that are universalizable, impartial, concerned with describing what is right.

This perspective varies from the dominant approach to bioethics in nursing, called ethical principlism (see discussion in Chapters 3 and 6). The “four principles of biomedical ethics” (respect for autonomy, nonmaleficence, beneficence, and justice), in wide use since the 1970s, promulgated by Beauchamp and Childress in their landmark work Principles of Biomedical Ethics,28 and utilized in The Belmont Report,29 provide the prevailing approach to bioethics in clinical practice, on institutional ethics committees, and in the current bioethical literature in medicine and nursing. Instead, Tronto advocates for a contextual morality, an ethic of care.30

An ethic of care has four sequential phases: caring about, taking care of, care-giving, and care-receiving.31 Caring about requires the recognition that care is necessary and an assessment of what the needs for care might be. Caring about is “culturally and individually shaped.”32 Taking care of “involves assuming some responsibility for the identified need and determining how to respond to it”33 and involves concepts of agency and responsibility. Care-giving involves directly meeting the needs for care and generally (“almost always”) involves direct contact. Providing the money for care activities “is more a form of taking care of than it is a form of care-giving.” 33 Care-receiving requires that

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the object (person, recipient) of care respond to the care received. This is “the only way to know that caring needs have been met.”34 Care-receiving serves another function as well. It prevents the care-giver from making assumptions about what care is needed or how the need should be met without actually determining this in mutuality and communication with the recipient of care.35

While Gastmans, as noted above, views care as a virtue, Tronto maintains that care is a practice and neither a principle nor an emotion. As a practice, it involves both thought and action that are interrelated and directed toward a specified end. She calls it “practical rationality.” 36 What guides this practical rationality toward care? Here, all four phases of care and the related four moral elements of care must be employed as an integrated whole for care to be demonstrated.

In addition to the four phases of care, there are four corollary moral elements: attentiveness, responsibility, competence, and responsiveness.36 Attentiveness requires recognizing need; ignoring, or ignorance of, others and their need is regarded as a moral failing or moral evil. Tronto points to several issues regarding attentiveness. First, one must both be attentive to one’s own needs for care, and be able to set them aside in order to see the care needs of others. Overidentification with the care recipient is also to be avoided. In an ethic of care, responsibility becomes “a central moral category.”37 Responsibility differs from obligation in that “responsibility is embedded in a set of implicit cultural practices, rather than a set of formal rules or series of promises. …we are better served by focusing on a flexible notion of responsibility than we are by continuing to use obligation as the basis for understanding what people should do for each other.”38 Thus, responsibility is more flexible, creative, and generous than is obligation. Competence is the third moral element: “how could it not be necessary that the caring work be competently performed in order to demonstrate that one cares?”39 Responsiveness is the fourth moral element. It distinctively refers to the responsiveness of the care receiver to the care given as well as the responsiveness of the care-giver to the care-receiver. This dual responsiveness works to prevent both the domination and subordination that can occur in unequal relationships and any abuse of care-receiver vulnerability.40

Tronto takes note of the vulnerability and inequality that intrinsically exist in relationships of care. The one who needs care is made vulnerable by that very need. That vulnerability intrinsically entails a loss of autonomy to some degree, making one dependent upon another to have that need met. The use of abstract, allegedly value-neutral, universal moral principles such as respect for autonomy is at odds with Tronto’s ethic of care.

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Benner and Wrubel noted early on that nursing and care are both devalued. They too reject an ethics of abstract, universal, decontextualized, rational principles. They write that:

In a highly technical society that values autonomy, individualism, and competitiveness, caring practices have always been fragile, but this societal blindness causes those who value technological advances to overlook the ways these advances are rendered dangerous and unfeasible without a context of skillful, compassionate care. The dominant view of knowledge in the Western tradition emphasizes abstract, general, theoretical knowledge while overlooking and devaluing local, specific, practical knowledge and expert skillful clinical judgments about particular clinical situations.41

The devaluing of care is important as it affects nursing within the institutions and agencies that employ it. However, the devaluing of care is important in the larger global context, a concern of Provisions 8 and 9. An important body of literature has developed on the devaluation of care as intimate labor.42 Intimate labor is largely behind the scenes labor that is not seen as having the same economic value as, for instance, the fees for nursing care that are folded into a room charge. Nursing falls at the high end of the continuum of intimate labor while housekeeping and childcare fall at the lower end. The concerns of this body of literature are that care is socially and economically devalued. Parreñas and Boris write that “intimate labor emerges as a mechanism that maintains and reflects socioeconomic inequalities.”43 What is important here is that care activities (including nursing care) as forms of intimate labors are tied to economic structures that perpetuate inequality and support a wide range of unjust structures. Issues of social justice will be discussed under provision 9. Care, an ethic of care, and the devaluing of care must be examined beyond the immediate relational context of nursing.

One of the breakthroughs of Tronto’s approach to an ethic of care is that she situates an ethic of care within the larger context of politics and the shape of society. When an ethics of care is framed within a socio-political context it has a clear touch-point with nursing’s social ethics, especially its concerns for health disparities (see Provisions 8 and 9). But more specifically, she analyzes the place of care in American society as it relates to power and privilege, noting that care is “gendered, raced, and classed.”44 Tronto’s ultimate goal is the political re-valuing and centering of an ethic of care.

An ethic of care takes account of the contextual realities of our human lives and, for nursing, provides a capacious moral climate for patient care as well as a perspective for the aims of nursing’s social ethics. In an ethic of care, the patient is central, having her or his own contextually shaped care needs. In an ethic of care, the larger social, political and natural environments are also in need of care.

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2.2 Conflict of Interest for Nurses

An ethic of care recognizes that care, even good care, involves conflict in a number of ways, not the least of which is that “often care-givers will find that their needs to care for themselves come in conflict with the care that they must give to others.”45 The classic example of this is the nurse in an emergency situation, for example, caring for injured fire fighters in an emergency department, when her or his own family may be in the wildfire evacuation area.

Care-giving may also involve other sorts of conflicts such as caring for a patient whose lifestyle is reprehensible, or caring for an enemy combatant, or caring for a patient who is deeply prejudiced and bigoted. Nurses care for patients and need not agree with or support the value structure of the patient, but work for the patient’s health, healing, and well-being nonetheless.

An actual conflict of interest refers to situations that place the nurse in a position where a choice must be made between the nurse’s own self-interest and the patient’s interests. The moral presumption of the nurse–patient relationship in principle-based ethics is that the best interests of the patient will be served. In an ethic of care, conflict of interest strains the larger moral notions of attentiveness and responsibility and the overall framework of the four care phases. The existence of a conflict of interest does not, however, presume that the nurse will make a morally inappropriate choice, but only that the circumstances of the situation raise the risk of such decisions. Several important relational elements come into play in a conflict of interest: 46

1. A relationship must exist, whether personal or professional.

2. If it is a professional relationship, then there are common role-related expectations and responsibilities.

3. A professional relationship is one of trust with an expectation of loyalty.

4. The nurse’s attentiveness has led to the identification of the patient’s need(s) for care.

5. Some aspect of the nurse’s own self-interest comes into play.

6. The nurse can choose to exercise self-interest over the care need of the patient.

7. Both the nurse’s self-interest and the patient’s care need(s) conflict.

While conflicts of interest in nursing need not involve money, they often do. For example, School Nurse Davy, as the children call him, serves in three schools in a resource-poor school system. He has far more children to care for than time or resources allow but he still tries to personally involve both the young students and families in caring for their specific health needs. Due

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to the new state lottery, additional funds derived from the lottery will be allocated to public schools. His three schools would be given extra funding for the school health and student lunch programs if he can demonstrate that the student services quota (number of students seen) has been met. He has been asked to quickly run a number of hearing and vision tests, and also to categorize some of his classroom visits for hygiene and nutrition lectures as separate student contacts in order to raise the school’s student services contacts above the quota. Interpretive Statement §2.2 acknowledges financial incentives and that “Healthcare financing and delivery systems may create conflict between economic self-interest and professional integrity.”47 Here the economic self-interest is even more complex in that it involves additional needed funding that would serve the students, and indirectly benefit the school health program. It challenges Nurse Davy’s integrity and compassion— without actually putting money into Nurse Davy’s pocket. In situations of conflict of interest, the 2015 Code directs nurses to “address such conflicts in ways that ensure patient safety and that promote the patient’s best interests while preserving the professional integrity of the nurse and supporting interprofessional collaboration.”48

2.3 Collaboration

This interpretive statement focuses on collaboration with others, including the patient, to meet patient needs. This differs from collaboration as discussed in the eighth provision, which is collaboration to achieve larger health goals and ends beyond the bedside (see Chapter 8). Here the focus is on the nurse’s commitment to the patient and therefore to collaboration that best serves to meets the care needs of the patient. As early as the Suggested Code of 1926, it was recognized that more than one discipline would be necessary to achieve the aims of health care: “The key to the situation lies in the mutuality of aim of medicine and nursing; the aims, to cure and prevent disease and promote positive health, are identical, the technics of the two are different and neither profession can secure complete results without the other.”49

In the 1950, 1957, and 1960 Codes, there is a reference to the healthcare team. Initially, that reference is to sustain confidence in the physician and team, then subsequently to work harmoniously with the team. These, then, are not references to collaboration but do acknowledge indirectly that more than a single discipline delivers patient care. The team disappears from the 1968 Code, though there are references to working with others to achieve social (rather than patient care) ends. The healthcare team again receives mention in the 1976 Code, but only in reference to the disclosure of information necessary for the team to give appropriate patient care.50 Provision 6 in the

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1985 Code contains a section (§6.3) on consultation and collaboration for patient care:

The provision of health and illness care to clients is a complex process that requires a wide range of knowledge, skills, and collaborative efforts. Nurses must be aware of their own individual competencies. When the needs of the client are beyond the qualifications and competencies of the nurse, consultation and collaboration must be sought from qualified nurses, other health professionals, or other appropriate sources. Participation in intradisciplinary or interdisciplinary teams is often an effective approach to the provision of high quality total health services.

This is not the most rousing endorsement of collaboration, rather it is collaboration based on necessity. It is not until the 2001 Code that collaboration is more positively embraced, as both intra and interprofessional collaboration:

Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal. In health care, that goal is to address the health needs of the patient and the public. The complexity of healthcare delivery systems requires a multi-disciplinary approach to the delivery of services that has the strong support and active participation of all the health professions…Intra-professional collaboration within nursing is fundamental to effectively addressing health needs of patients and the public.51

The 2015 revision retains this more positive view of the essential nature of collaboration for patient care:

The complexity of health care requires collaborative effort that has the strong support and active participation of all health professions. Nurses should actively foster collaborative planning to provide safe, high- quality, patient-centered health care…. Collaboration within nursing is essential to address the health of patients and the public effectively.52

In the discussions of collaboration, there is a trajectory across the successive revisions of the code that reflects the social location of nursing, the scientific development of nursing and medicine, specialization, changing nursing practice and advancing nursing roles, and an increasing complexity of healthcare delivery systems. Initially discussions are about working with physicians and sustaining confidence in the physician. Then working harmoniously with the physician and other healthcare professionals emerges. This begins the shift toward using the language of “other health professionals” and a decrease in mention of the “physician.” Working with others becomes collaboration as nursing theory and research increases the identification of the distinctive

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differences between nursing and medicine; that is, as nursing tries to separate itself as a profession from medicine. The language used for collaboration at this point displays an uneasy tension between nursing and medicine. As both nursing and medicine become increasingly specialized, and as healthcare systems become more complex, collaboration is embraced by both because more specialized knowledge is needed and also because failure to collaborate leads to all the hazards of the fragmentation of patient care. High-quality patient care cannot exist without welcoming and embracing both interdisciplinary and intradisciplinary collaboration in today’s healthcare system.

2.4 Professional Boundaries

The fundamental nature of the nurse–patient relationship is therapeutic, not personal. In addition, the fundamental nature of the healthcare team relationships is professional, not personal. This revision of the interpretive statements is rather more direct than any previous code in its declaration: “Dating and sexually intimate relationships with patients are always prohibited…. Boundary violations can also occur in professional colleague relationships. In all communications and actions, nurses are responsible for maintaining professional boundaries.”53 The 2001 Code’s allusion to more intimate relationships with team members is indirect and previous codes, where they dare, only vaguely hint at such indiscretions.

Another boundary violation, bribery, is mentioned in the first adopted code in 1950. Its Provision 10 says: “The nurse accepts only such compensations as the contract, actual or implied, provides. The professional worker does not accept tips or bribes.”54

The language of tips and bribes then disappears from successive codes. The issue of gifts, as opposed to bribes, is different. Gifts are expressions of gratitude, bribes are “a reward given to pervert the judgment or corrupt the conduct.”55 The purposes of gifts are morally praiseworthy; the purposes of bribes are morally blameworthy. Gifts were a concern in the early modern nursing literature when nursing care was delivered in the home. They might be personal expressions of gratitude by a family or a patient, or they might be the annual or seasonal bonus that would be given to all household attendants. The same is true of private duty nursing in the hospital before hospitals employed staff nurses and instead students to staff the hospital. Discussion of gifts is minimal in the nursing literature. In hospital contexts, recommendations have traditionally been that gifts given by patients should be directed toward the staff of the unit rather than toward an individual nurse. The issue of gifts has become a concern once again but this time as an issue of cultural context, awareness, and sensitivity. The guidelines that are now offered are that “accepting gifts from patients is generally not appropriate; factors to consider

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include the intent, the value, the nature and the timing of the gift as well as the patient’s own cultural norms. Gifting members of the healthcare team is closely linked with healing and recovery in some cultures. When a gift is offered, facility policy should be followed.”56

Provision 2 is focused on the patient as the first allegiance of the nurse and on the primacy of the patient’s interests. These are best affirmed by a deep and guiding understanding of the moral nature of the nurse–patient relationship. That understanding serves to help draw and to keep appropriate therapeutic boundaries in place. When the nurse–patient relationship is seen within an ethic of care, the more complete context of that relationship also helps to demarcate and maintain professional boundaries between and among members of the healthcare team.

Cases

Case 1

Anaya Praben, a 32-year-old woman, is in persistent vegetative state and has been for some years. The patient’s outdated advance directive is confusing on the issue of food and fluid, though clear about not wanting to be on a ventilator if she were in a coma. Her husband wants the feeding tube removed, but is unable to say that it would have been the patient’s wish. He says that it is his decision for her. Her two siblings and parents reject this as a possibility because, they say, “human life is sacred” and that their daughter believed this. They say their daughter is alive and should receive nursing care, including feeding. The healthcare team disagrees on what to do ethically. The parents ask the nurse if they might attend the next patient care conference.

Case 2

Hundreds of refugee immigrants have recently been relocated to a rural county leading to a significant shortage of influenza vaccine. The County Health Department has decided to temporarily restrict this vaccine only to pregnant women and elderly people who are 60 years of age or older and who are US citizens until such time as additional vaccine might become available. The potential availability of additional vaccine in the coming weeks is uncertain. The immunization clinic nurse is worried about exposure to the flu from the clinic population then taking it home and exposing his family. He figures they are at higher risk because of his job. He is considering taking some of the vaccine home to give shots to his family.

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ENDNOTES

All URLs were current when accessed on January 9, 2015.

1 R. Corwin, “The Professional Employee: A Case Study of Conflict in Nursing Roles” American Journal of Sociology 66, no. 6 (1961): 604–15.

2 Andres Oldenquist, “Loyalties,” The Journal of Philosophy, 79, no. 4 (April 1982): 175–76. 3 Ibid., 176. 4 Ibid., 178–79. 5 Lystra Gretter, The Florence Nightingale Pledge (Detroit, MI: Farrand Training School for Nurses,

1893). 6 Corwin, “Professional Employee.” 7 Note that an ethic refers to a theory or system of moral values, such an “ethic of care.” The term

ethics (which is singular, not plural) refers to the field of study of moral analysis, choices, and behavior; that is, to philosophical or theological reflection upon morality.

8 Lawrence Kohlberg, “Moral stages and moralization: The cognitive-developmental approach,” in Moral Development and Behavior: Theory, Research and Social Issues, ed. T. Lickona (Holt, NY: Rinehart and Winston, 1976).

9 Carol Gilligan, “In a Different Voice: Women’s Conceptions of Self and Morality.” Harvard Educational Review 47, no. 4 (1982): 481- 517.

10 Ann M. Beutel and Margaret Mooney Marini, “Gender and Values,” American Sociological Review 60, no. 3 (June 1995): 436–448. See also: Maureen R. Ford and Carol R. Lowery, “Gender Differences in Moral Reasoning: A Comparison of the Use of Justice and Care Orientations,” Journal of Personality and Social Psychology 50, no. 4 (1986): 777–83; Mary Rothbart, Dean Hanley, and Marc Albert, “Gender Differences in Moral Reasoning,” Sex Roles 15, nos. 11 and 12 (1986): 645–53; D. L. Krebs, S. C. Vermeulen, K. Denton, and J. I. Carpendale, “Gender and perspective differences in moral judgment and moral orientation,” Journal of Moral Education 23, no. 1 (1994): 17–26.

11 Nel Noddings, A Feminine Approach to Ethics and Moral Education (Berkeley: University of California, Berkeley Press, 1984).

12 Joan Tronto, “An Ethic of Care,” in Feminist Theory: A Philosophical Anthology, eds. A. Cudd and R. Andreasen (Oxford, UK: Malden-Blackwell Publishing, 2005), 251–63.

13 Joan Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (London: Routledge, 1993).

14 Annette Baier, “What Do Women Want in a Moral Theory?” Noûs 19, no. 1 (March 1985): 53–63.

15 Patricia Benner and Judith Wrubel, Primacy of Caring: Stress and Coping in Health and Illness (Reading, MA: Addison-Wesley, 1989).

16 Virginia Held, The Ethics of Care (Oxford, UK: Oxford University Press, 2005). 17 Selma Sevenhuijsen, Citizenship and the ethics of care: Feminist Considerations on Justice, Morality,

and Politics (London: Routledge, 1998). 18 Michael A. Slote, The Ethics of Care and Empathy (London, New York: Routledge, 2007). 19 Jean Watson, Nursing: The Philosophy and Science of Caring (Denver, CO: University of Colorado

Press, 1985). See also: Jean Watson, Caring Science: A Core Science for Health Professions (Philadelphia, PA: FA Davis, 2004).

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20 Madeline Leininger, ed., Caring: The Essence of Nursing and Health (Detroit, MI: Wayne State University Press, 1980).

21 Simone Roach, The Human Act of Caring (Ottawa: Canadian Hospital Association, 1992). 22 A brief overview of the development and an analysis of an ethics of care can be found in:

Chris Gastmans, “The Care Perspective in Healthcare,” in Essentials of Teaching and Learning in Nursing Ethics: Perspectives and Methods, The Teaching of Nursing Ethics: Content and Methods, eds. Anne Davis, Louise de Raeve, and Verena Tschudin (London: Elsevier, 2006), 135–48.

23 More information about the International Care Ethics (ICE) Observatory can be found at this website: http://www.surrey.ac.uk/fhms/research/centres/ICE/index.htm

24 Patricia Benner, Molly Sutphen, Victoria Leonard, and Lisa Day, Educating Nurses: A Call for Radical Transformation (New York: Jossey-Bass/Carnegie Foundation for the Advancement of Teaching, 2009), 222.

25 Chris Gastmans, “The Care Perspective in Healthcare Ethics,” in The Teaching of Nursing Ethics: Content and Methods, eds. Anne Davis, Louise de Raeve, and Verena Tschudin (London: Elsevier, 2006).

26 Tronto, Moral Boundaries. 27 Bernice Fisher and Joan Tronto, “Toward a Feminist Theory of Care,” in Circles of Care:

Work and Identity in Women’s Lives, eds. Emily Abel and Margaret Nelson (Albany, NY: State University of New York Press, 1991), 40.

28 Tom Beauchamp and James Childress, Principles of Biomedical Ethics (1st ed.) (Oxford, UK: Oxford University Press, 1979).

29 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research of the U.S. Department of Health and Human Services, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research (Washington, D.C.: DHHS/USGPO, 1979), available at http://www.hhs.gov/ohrp/humansubjects/guidance/ belmont.html

30 Tronto, Moral Boundaries, 27. 31 Ibid., 106–08. 32 Ibid., 106. 33 Ibid. 34 Ibid., 108. 35 Ibid., 109. 36 Ibid., 109. 37 Ibid., 131. 38 Ibid., 132. 39 Ibid., 133. 40 Ibid., 134–136. 41 Patricia Benner and Judith Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness

(Menlo Park, CA: Addison-Wesley, 1989), xv. 42 Rhacel Parreñas and Eileen Boris, Intimate Labors: Cultures, Technologies, and the Politics of Care

(Stanford, CA: Stanford University Press, 2010), 3. 43 Ibid., 10. 44 Ibid., 113. 45 Ibid., 109.

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46 Bernard Lo and Marilyn Field, eds., Conflict of interest in Medical Research, Education, and Practice (Washington, DC: Institute of Medicine/National Academies Press, 2009).

47 American Nurses Association, Code of Ethics for Nurses with Interpretive Statements (Silver Spring, MD: ANA, 2015), 6.

48 Ibid. 49 ANA, “A Suggested Code,” American Journal of Nursing 26, no. 9 (1926): 600–01. 50 ANA, Code for Nurses with Interpretive Statements (Kansas City, MO: ANA, 1976), 6. 51 ANA, Code of Ethics for Nurses with Interpretive Statements (Silver Spring, MD: ANA, 2001), 15. 52 Ibid., 14–15. 53 Ibid., 16. 54 ANA, A Code for Professional Nurses (New York: ANA, 1950), Provision 10. 55 Oxford English Dictionary Online, “Bribe,” accessed on Month day, 2012, http://0-www.oed.com.

patris.apu.edu/view/Entry/23151?isAdvanced=false&result=1&rskey=8CFta9& 56 ANA, Code of Ethics for Nurses with Interpretive Statements(2015), 7.

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