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Module 2C: Patient - Nurse Relationships

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Melissa Yates

on 12 September 2018

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Transcript of Module 2C: Patient - Nurse Relationships

Module 2C: Patient-Nurse and Doctor-Nurse Relationships
Role Obligations of Nurses
Lisa Newton, "In Defense of the Traditional Nurse"
Helga Kuhse, "Advocacy or Subservience for the Sake of Patients?"
Biomedical Ethics

1. Lisa Newton, “In Defense of the Traditional Nurse”, 88-95.
2. Helga Khuse, “Advocacy or Subservience for the Sake of Patients?” 95-103.

Bioethicists often emphasize the ethical dimensions of the relationship between physicians and patients. But this neglects the important role played by nurses, and the unique ethical challenges they face in their relationships with patients. While there are some ways that this relationship is similar to that between physicians and patients, there are also many unique features.
Background: What is the feminist objection to the image and ideal of the traditional nurse?
Newton's essay in defense of a revised version of the traditional ideal of nurses is premised on the assumption that the dominant view commonly accepted is that such an ideal is morally problematic. This essay, from 1981, is a rebuttal to those objections which (according to Newton) had already successfully transformed the ways nurses conceived of their own ideal.

Importantly, Newton is not targeting the personal images or ideals that a nurse may have of him or herself. She's targeting the public ideal, or that which we in society value in the role of nurses.

The traditional image (descriptively) and ideal (prescriptively) are criticized by feminists for devaluing the education, intelligence, and experience that qualifies nurses to offer medical advice and treatments, and as wholly subservient to physicians based on sexist hierarchies where women are seen as subservient to men.

The traditional nursing image is also criticized for leading to systematic underpayment of nurses, and for failing to provide adequate professional protections and opportunities for promotion.

Newton agrees with these criticisms of the traditional nursing model. But she argues that there's a better version of the traditional nursing ideal that is not open to these same charges, and that is a serious competitor with the feminist alternative ideal of the nurse as autonomous professional.
Lisa N. Newton, Fairfield University
American bioethicist

Dr. Newton earned her Ph.D. from Columbia University, has directed a dozen projects in environmental and bioethical ethics from 1979 forward, and has published dozens of articles, many of which have appeared in applied ethics textbooks.
Picture from: http://theccfblog.org/the-many-career-paths-of-a-nurse/
Picture from: http://correctionalnurse.net/2014/07/05/correctional-nurse-guide-to-the-code-of-ethics-relationship-to-patients/
Some of the similarities between physician-patient and nurse-patient relationships:

both commit to promote the health of their patients using their medical expertise
both have to balance the well-being of patients with respect for patient autonomy
both have to find ways of translating technical information to patients
both have to manage their own personal ethics alongside professional role obligations

Some of the differences:
nurses are usually directly responsible for patient care and implementing therapy
nurses generally have less power in the decisions about patient care than doctors
obligations to doctors and patients might conflict
Quick reminder note about role obligations:

these are obligations/duties that we have because we have adopted some role -- as a parent, a spouse, an employee, a student, etc.

many ethical theorists argue that we also have obligations/duties in virtue of our humanity, regardless of roles that we adopt. (not to lie, cheat, steal, for instance)

when thinking about the unique obligations that nurses have we're talking about their "role obligations", and those arguments have to connect with features of the role nurses play in their relationships with patients, their families, and other medical professionals.
Argument Reconstruction
a. Role ideals are normative, while role images are descriptive
b. Private role ideals and images refer to a person's own view about his or her role, while public role ideals and images refer to the view people in the broader society outside that role have of people who occupy those roles
c. In general, the public and private images of nurses are consistent, while the public and private ideals of nurses are inconsistent

1. There is a much better defense of the public ideal of traditional nurses than the one criticized by feminists.
Feminists have criticized the public's ideals of traditional nurses as sexist in the insistence that nurses be wholly subordinate to physicians. These criticisms amount to strawman arguments, because they attack a view of nurses which nobody holds (or virtually nobody holds).
2. The public's ideal of the traditional nurse as subordinate to physicians addresses the realities of both the work conditions within hospital bureaucracies and within the practice of medicine better than the autonomous professional model..
With respect to bureaucracies, if nurses were autonomous there would be inefficiencies with respect to procedures because the hierarchy for decisions in medical emergencies would be unclear. With respect to the practice of medicine itself, only physicians have the education needed to make emergency medical decisions and they should not have to slow down progress to justify themselves to nurses.
3. The public's ideal of the traditional nurse promotes the well-being of patients better than the autonomous professional model.
Every role ideal serves someone else besides oneself -- clients, customers, patients, etc. So, while the nurse might find his or her role more rewarding if autonomous, the point of the nurse's job is to serve patients, not her or his own needs. Often patients undergoing serious medical treatments find the experience of being taken care of humiliating and find comfort in experiencing the nurse as mother-like. Patients benefit from being able to talk freely with nurses about anxieties and frustrations without worrying that it could affect their treatment plan. Patients and their families often benefit from nurses in their traditional role as the humanizing face of hospitals.
4. The ideal of the traditional nurse as subservient to physicians is not intrinsically harmful to nurses and is compatible with treating nurses as autonomous persons in other respects.
There's a difference between treating persons as autonomous, and having an autonomous role in one's workplace. Very few people have jobs where it would be appropriate for them to be entirely professionally autonomous and self-determining. Most of us have jobs whose role is subservient to bosses in some kind of hierarchy. But the hospital hierarchy is not disrespectful of nurses' having their own self-determination with respect to the rest of their non-work choices. So, unlike the role ideals of slaves and traditional housewives, the role ideal of nurses is not morally objectionable for disrespecting the humanity of the nurse.
Therefore, the public ideal of the traditional nurse is morally preferable over the private ideal many nurses have of themselves as autonomous professionals.
How do you think Newton would respond to the arguments advanced in this video? Does this pose an important objection to her argument? If so, which step in her argument is threatened?
An example of the campaign to promote nurse professional autonomy, from West Penn Hospital, 2012
From: http://www.adventuresofpolly.com/wp-content/uploads/2011/07/doctor-education1.gif
From: https://www.ahn.org/sites/default/files/image/PPM-modifiedMay2012.jpg
From: http://www.utmedicalcenter.org/lib/image/thumbs/Professional_Practice_Model_450_582_450_582_450_582.jpg
Helga Kuhse, Associate Professor, Monash University
Australian bioethicist

A utilitarian philosopher, Dr. Kuhse co-founded the Centre for Human Bioethics at Monash University with renowned ethicist Peter Singer in 1980, one of the first of its kind. She served as Director from 1992-1998. She and Professor Singer also founded the journal "Bioethics" in 1987, has served on many ethics committees, and has provided expert testimony in the Australian Parliament on one of her most famous interests: the ethics of end of life decisions and euthanasia (which she supports).
Main Points from "Advocacy or Subservience for the Sake of Patients?"
Essentialism and naturalism: Kuhse's article begins by arguing that the roles of nurses are not something that can be defined along essentialist grounds, in terms of what a nurse is by nature. An essentialist would have to argue that the idea of a nurse contains within it the essence of what a nurse is (like the idea of a bachelor contains its definition: an unmarried man). Kuhse argues that whatever a nurse is, and whatever the role of a nurse should be is something that is socially constructed by our conventions. To say that a nurse should be subservient is simply to say that according to our social conventions nurses should be subservient. Nurses cannot be subservient or autonomous by nature, because the idea of nurses isn't necessitated by nature.

Against Newton's argument from efficiency (99): Kuhse grants that hospitals are bureaucratic, and that they need some organized hierarchy to function as smoothly as possible. But granting that does not determine what the relationship between nurses and doctors should be. Instead, Newton would have to give an argument as to why doctors should be in charge, instead of nurses, which she doesn't. ... Question: What do you think Newton would say about this? Kuhse anticipates that Newton would respond that doctors should be in charge because they have more medical expertise, which prompts her to reply as follows.

Against Newton's argument from expertise (99-100): Kuhse grants that there is a place for doctors to have authority over largely subservient nurses -- in the operating room or in medical emergencies. But this is only a general rule, and there are exceptions. For instance, nurses shouldn't blindly follow a doctor's orders, even in emergencies, if she or he has reason to think the doctor's order is clearly wrong. In such cases nurses should act as patient advocates and not merely serve the doctor. Nurses should adopt a prima facie rule that they follow the doctor's orders in medical emergencies, but that rule can be overridden and is not absolute.

Argument concerning reasonable disagreement over therapeutic goals (100, 102): Kuhse also argues that there are many cases where a doctor's medical expertise does not settle a dispute over different possible therapeutic treatment options, because often the patient's values and wishes come into play when deciding how to proceed. Whether to reduce pain or prolong life, for instance, are two potentially different goals. The doctor's medical expertise does not help decide which the patient should pursue.

Argument against the assumption of urgency (101): While the best outcomes may be secured by a transitional doctor-nurse hierarchy in emergencies, the same cannot be assumed in the many non-emergency cases.

Argument against nurse-mothers (101-102): It is an enormous assumption that all or most patients need/want their nurses to play a quasi-mother role for them. And even if the nurse were to act as a sounding board for the complaints and anxieties experienced by the patient, if the nurse is wholly subservient to he doctor patients are likely to feel as though what they're saying isn't being taken seriously.

Argument regarding the nurse's experience of subservience (102): Nurses will likely find the role of a traditional nurse as "utterly demoralizing" because such a role requires that they follow doctor's orders even when they conflict with the nurse's judgment about what's best for patients.
Photo from: http://media.cmgdigital.com/shared/img/photos/2013/04/04/69/d0/shutterstock_126288149myddn.jpg
Full transcript