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Conscience and courage — a critical examination of professional conduct
NursrEducahn Today (1990) 10.3-9 0 Longman Group UK Ltd 1990
0260 69 17/90/00
Conscience and courage of professional conduct
IO-0003/$10.00
a critical examination
Ruth A Schrbck
The roots of professional power and authority lie in the claim to a specific kind of knowledge, the ‘knowledge that’ and the ‘knowledge how’. These kinds of knowledge are included in the notion of ‘science’. ‘Knowledge why’ - the justification for a professional action - demands a moral argument in terms of what is known and can be done (taking ‘scientific’ knowledge into account) but most importantly asking whether it ought to be done. It is important to ask how a nurse acquires the ‘knowledge why’ and thereby the means to justify his/her conduct in moral terms. This paper considers the norms of professional conduct, the professional mandate and the determination of what is, to the best of the professional’s knowledge and conscience, the right act. The question is raised whether an appeal to the individual conscience can be a reliable guide to a morally justifiable action. An exploration of moral perceptions, moral reasoning and moral argument needs to be part of a professional education which requires a certain kind of courage on part of both teachers and students.
A SPECIAL RESPONSIBILITY It has been suggested that one of the roots of professional authority and power lies in the claim to a specific kind of knowledge which is to be used without discrimination for the benefit of those who are in need of it (Schrock 1982, pp104-105.) While reminding ourselves that the knowledge which professions suggest they have is often not anything as unique, inaccessible or general as the public has been led to believe, common sense would expect that people who
Ruth A Schdck MA PhD DNS(Educ) SRN RMN RNT, Professor of Nursing and Social Sciences, Fachhochschule Osnabriick, Albrechtstrasse 30,450O Osnabriick, Germany (Requests for offprints to RAW Manuscript accepted 1 June 1989
study in a particular field over a number of years ought to know something that others do not know. Personal experience, if nothing else, also tells us that knowledge is indeed power. Anyone who knows little of the workings of a car engine and who ‘needs’ the knowledge which a car mechanic can offer, will be able to attest to his or her vulnerability, or at least to that of their purse. It is self-evident that people can get hurt by the misuse of knowledge which they expected another person to acquire and use for their benefit rather than to their detriment. It is an essential part of higher education, and its main function, to create and develop knowledge, to teach others how to do likewise and how to use knowledge effectively and responsibly. The academic teacher will emphasise such criteria as the
reliability
know,
insist
and
validity
on a balanced
of what
we claim
presentation
to
a.nd 3
4
NURSE EDUCATION
TODAY
intellectual honesty, and even convince the student that it is essential to know what we do not
that all knowledge
is somehow
and derived
‘science’,
know. All these endeavours
perceived are rightly
emphasised
sciences.
throughout the student’s progress towards the chosen goal but are largely restricted to a particular kind of knowledge.
No doubt, irreparable
the property
where
to be synonymous a justification,
is known
and
possibly of
of
‘science’
is
with the empirical
An answer to the question
constitute what
from
what
‘why’ would in terms
can
be
of
done.
However,
what is possible in terms of (narrowly
scientific)
knowledge
harm could befall a patient who relied on the nurse’s knowledge of passing a tube into his
same as what ought to be done.
In the offered
stomach so that he could receive nourishment
example,
to pass a tube
a safe and adequate unable to breathe trachea
way and then found himself
as the tube had ended up in his
due to the practitioner’s
Of course,
in
the nurse
well how to perform
ignorance.
this procedure,
very
and the skill
required may have been founded on sound, systematic knowledge and both theoretical and He could
practical
understanding.
negligent
or might have allowed his knowledge
to be used for evil purposes torture.
like punishment
nurse was in fact knowledgeable justify would
have been or
If the latter were the case, that is, the
or by adopting
but negligent,
values which may in his mind
punishments
or torture,
be no use in increasing
clearly
there
his knowledge
how
to perform this procedure. Neither would there be much point in adding to his knowledge that the relevant particular
anatomy structures
and physiology and processes.
whether
a degree
justified All
of negligence
professions
have
create and develop practical knowledge titioner
or punishment
1987, pp8-21)?
the
responsibility
relevant theoretical which permits the
to utilise in his work whatever
to and prac-
can be
known at any given time; but when we add that what he knows and can do must be used only to the patient’s
or client’s
benefit,
we express
a
moral principle. A special responsibility is laid on the profession collectively and carried by each practitioner individually which requires certain kinds of conduct
and prohibits
through
trachea
and cause fluid to pass
it. It certainly can be done but few of us that it ought
to be done.
Know-
ledge of what ought to be done is only partially derived
from
theoretical
and
practical
know-
ledge. We must develop and accept ‘A view of knowledge the sphere
that acknowledges
of knowledge
sphere of ‘science’.
is wider
(as)
or of science.’
It is pertinent nurse
the
. . a. . . necessity, if
we are to arrive at a sane and human ourselves
that
than
(Putham
view of
1978, p5)
to ask in what way the individual
acquires
this
wider
knowledge
and
thereby the means to justify his conduct in moral terms, that is, as being right in addition to being possible.
in
by these or any other means are ever
(Downie & Calman
into a person’s
possible
consist of Where,
knowledge that and knowledge how could we look for an answer to the moral questions and torture
it is obviously
would accept
may have known
and skills is not at all the
others.
Knowledge why a nurse or any other health care worker may choose to do one thing rather than another includes knowledge that and knowledge how but it is a seriously mistaken view
NORMS OF PROFESSIONAL CONDUCT Sociologists
tell us that one of the characteristics
of a profession
is its authority
ards of behaviour cating
disputes
regulation
in setting
for its members about
their
conduct.
This
in the context of a professional
based on a number
stand-
and in adjudiself-
ethic is
of claims which include that
the profession: 1) is entitled principles
to generate its own norms and governing correct professional
conduct 2) is the only body having knowledge of what is morally required for its members 3) is the only group capable of adjudicating moral disputes related to professional conduct 4) has a responsibility for discipline on its members
imposing
moral
NURSE EDUCATION
5) is empowered to articulate its own set of moral standards usually in the form of a code.
ually exercise
that
‘The existence
of a code or set of standards a characteristic group,
is
that it can
be used to resolve disputes over whether in an occupational
those
such as accountants
or appraisers or archivists, can be termed professionals.’ (Veatch 198 1, ~83)
real
which uses a series of characteristics
that established
professions
for other
aspiring
status
to professional Suffice
An examination
argument
1987,
is a circular
of a somewhat
of historically
like medicine
(Schrock
it to say that by any standards
of logic the underlying concept
occupations
pre-eminent
idealised
professions
and law results in a set of formal
characteristics.
These
are by no means
realised
in everyday practice even by the established professions. Nonetheless, they are meant to provide a meaningful set of criteria by which to label
occupational
(Schrock This
groups
as
professions
1982). gets us no further
than
noting
profession is what I say it is. Rather more important questions the above claims to a professional determination constitutes
right and wrong.
question
must
professions conduct
by a profession surely
the professional
arise from
ethic with the
for itself of what The
be who
in general
which govern
most obvious
has authorised
to establish
principles
the relationship
worker
that a
of
between
and his or her clients?
To what extent, if any, should the general public be bound by the opinions of the council of a professional
body?
Hughes
describes
The central justification
for this mandate
ledged contract
or bargain
and equitable trol granted
benefits. to the
lies in
but acknow-
between
the profes-
resulting
in mutual
The autonomy and conprofessions over their
by the wider society
are part of this
bargain by which the professions
in turn guaran-
tee to the community
service of high
an expert
standard and by which they are compensated for the risk-taking which is inherent in the serious consequences or negligently
that a professional task inexpertly performed may have.
‘The issue of risk-taking the argument attendant
is a central
for professional
autonomy
of
point in
status with its
decision
making.
Therefore decisions need to be informed by expert knowledge with the ultimate justification for a professional
act that it is. to the best
of
knowledge
the
professional’s
science,
the right act.’ (Schrock
Although
there
are weak points
tionalist argument where
(Schrock
moment
and
in this func-
which I have examined 1987),
let us accept
this notion of a social contract
the professions
con-
1987, ~13)
and society.
Its essential
else-
for
the
between feature
that the privileges and power gained are necessary for the professional in order to use his or her expertise all members
unhindered
and to the benefit
of the community
expresses
which many of us would wish to see realised the greatest
of
an ideal to
possible extent. Neither would many of the
public
find
anything
in the moral principles
really
articulated
in professional codes of conduct. However, the decision of what is ‘to the best of the professional’s knowledge and conscience, the right
MANDATE
one of the mainsprings
to
. .’ (Hughes
the idea that there is an unwritten
objectionable
profession’s authority as the ‘professional date’ in the following terms:
do
1971, p298)
members
THE PROFESSIONAL
(presuming)
tell society what is good and right.
members
are believed to poss-
ess, as a set of criteria ~~12-15).
. . . (and) . . . individ-
sions and society in general
This is not the place to examine in detail the fundamental fallacy of the ‘trait’ or ‘inventory’ approach
mandate
a licence to do things others
not do (as well as) collectively
seen as so essential
one.
‘Professions, perhaps more than other kinds of occupation . . . claim a broad legal, moral and intellectual
Veatch observes
5
TODAY
of a man-
act’ can only ever be an individual one. The code of professional conduct for the nurse, midwife and health visitor published by
6
NURSE EDUCATION
the
United
TODAY
Kingdom
Nursing,
Midwifery
stresses,
for example,
Central
and Health
Council Visiting
privileged residence
allowed
obviously
tells them
relationship and of the
to their
property,
or workplace.’
that what they
did was wrong. Appeals to conscience
with patients/clients
access
conscience
the need to
‘Avoid any abuse of the privileged which exists
for
(1984)
subjective.
They
ment of rightness by
personal
authority
are clearly personal and
are founded
on a prior judg-
and wrongness
sanction
(Benjamin
rather
& Curtis
and motivated than
external
198 1, p96).
The person who feels guilty and who has a bad
This clearly does not tell the nurse what to do. The decision not to misappropriate a patient’s
conscience
belongings
maxim ‘don’t drink and drive’ as right. To put it
must be made by the individual nurse
in her own ‘knowledge
and conscience’
that this
is the right act which finds its justification only in the above statutory
another
1981, p96).
that exhorts
us not to
steal.
and driving has before
this
action
way - our conscience
of rightness
eral moral commandment
of
accepted
the
does not tell us
what is right or wrong, ‘it mustfollow ajudgment
by her
articulated
after drinking
commission
body but also in the gen-
principle
professional
not
the
or wrongness’
(Benjamin
& Curtis
Campbell (1984, ~23) has succinctly summarised this dilemma. ‘It seems that conscience is a powerful force in controlling the actions of most individuals . . .
THE APPEAL TO CONSCIENCE An explicit conscience
appeal
to the professional
is an integral
of the professional’s ~76) observes
person’s
part of the justification
autonomy.
Etzioni
(1964,
that
‘Students of the professions have pointed out that the autonomy granted to the professionals who are basically responsible consciences fessional
. . . is necessary
to their
for effective
pro-
work.’
The notion that the individual’s consicence is the final arbiter in deciding what it is right or wrong to do in a professional glance to be persuasive. only the individual
context
seems
at first
Having insisted that it is
who can and, indeed,
must
But although powerful, it may not always be right . . . After all, if everyone’s conscience always gave totally correct statements of the right actions in situations,
not two consciences
would ever differ. Yet, unless we support that everyone with different views from our own is either
totally ignorant
pulous, genuine
or completely
we know that disagreements
the guidance
of my conscience
may be right
for me, but not right for somebody Apart
from
the fact that
unscru-
there can be many of conscience. Thus
‘following
else.’ our con-
science’ may leave us with a disturbing sense of the relativity of all values, it would obviously be impractical
to provide
a coherent
service
for
decide what, to the best of his or her conscience,
people on this basis. There is a danger, in my view, that the uncritical appeal to one’s con-
the right act is, it then seems inescapable that it is our own conscience which directs our actions. The individual conscience as a guide to moral
science may on occasion be a form of self-indulgence. The values which we have internalised become an important constituent part of our
action may, however,
personality, contribute inform our self-esteem.
present
us with a difficult
problem. Our own experiences show that not everyone’s conscience directs its owner in the same way. Some people’s
conscience
tells them
that it is quite all right to drink and drive or to cheat the Inland Revenue. Other people, having driven home after a party or having failed to declare
an item of income,
feel guilty.
Their
is primarily
to our sense of self and An appeal to conscience
based on a desire to preserve
one’s
integrity or wholeness as a person (Benjamin & Curtis 198 1, p95). ‘I could not live with myself, we say, or ‘I could not face myself, when we maintain a certain stance as a matter of conscience. Really?
NURSE EDUCATION
Who does not recall some incidence hood, the first conscious
in child-
lie, a few stolen apples
or an act of disobedience
which
caused
the
perpetrator a truly sleepless night because of the loud and clear voice of conscience? Somehow, lying
becomes
progressively
easier
as we get
leagues
or the
especially
fear
of student Beardshaw’s
standing
their conscience
occasionally
and regretfully aware of a certain loss of moral sensitivity, we manage to live reasonably well with ourselves moral
most of the time. This process of
desensitisation
is, as we well know, also
part of the novice’s
socialisation
sion. It is eloquently
expressed
nurse
in an example
into a profesby a psychiatric
cited by Campbell
(1984,
‘ . . the trouble
is . . . that one tends
respond immediately
not to
to one’s sense that wrong
is being done. Thus the dictates of conscience become
less clear and are eventually
the extent that self interest over patient interest.’ When
objectors
it is in our
overcome
interest,
remain undisturbed ness and thought
it seems,
care
of mentally
appeal
to it in order
to
1979, ~316).
conclusion
people
set a high
turbed.
In a conflict of consciences,
at a searching
must be that
value on remaining
examination
expressed
if they complained
told them
of what
to be wrong
ill people.
in
‘Conscientious
One
in the
comment
is
typical of many. ‘My name would be blackened tainly I would be victimised, difficult
to get promotion
complaint
and most cer-
and (it would be)
- if I had to make a
of any sort.’ (Beardshaw
anticipated
unsettling
or
experiences
actual were
198 1, ~35).
disturbing clearly
and
weighed
against the distress caused by a guilty conscience. In most cases, nurses and eventually
find it easier to bear with
silence their conscience.
we can
about (our) own acts and their
A not unreasonable
participated of
on the one
in ‘. . . a mode of conscious-
value or disvalue’ (Childress
of
takes precedence
the pangs of conscience
hand or, on the other,
stifled to
out for fears
at work’ in mental hospitals
These
Pl9)
singled Nurses’
who
nurses
( 198 1) study
a fear of reprisals,
Although
duties.
being labelled as a trouble-maker by colleagues are very real indeed. More than three-quarters
older, stolen apples turn into expected perks of the job and disobedience becomes the virtue of up for oneself.
of being
unpleasant
7
TODAY
undis-
any attempt
of the values which
have directed
our ‘conscientious’
be disturbing.
A sense of uncertainty
response
must
and unease
is inevitable
when one permits possibly long held
convictions
to be questioned.
An apprehension
that one might not be able to justify
one’s moral
A CERTAIN KIND OF COURAGE It would
be easy
unwillingness professionals which
to attribute
of nurses to confront
they experience
way to a lack of personal
the
apparent
and of many other the moral dilemmas in a more courage.
constructive However,
this
seems to me patently unjust. We would not accuse a person who does not cross the Atlantic in a sailing boat of a lack of courage,
if they had
no knowledge
no skill in
of navigation
and
sailing a boat. If such an attempt
were made by
ignorant
we would call
and unskilled
persons
except by an embarrassing cliche may unease. The individual add to one’s undoubtedly reacts to this possibility of being disturbed by trying to avoid a genuine examin-
them stupid and foolhardy. I would not consider it cowardly to avoid a disputation with a nuclear
ation of the issues involved.
Clearly we expect that physical and intellectual courage must be based on sound knowledge
stance
consistent
appeal
A determined
to conscience
achieves
and just
physicist,
if I had no knowledge
that. Similarly, a bad conscience is a disturbing and unsettling experience but so are many other
accompanied
experiences
in a coherent
like being
rejected
by one’s
col-
of physics and
knew myself to be a poor debater.
by appropriate
skills.
Similarly,
moral courage requires a rational foundation and the ability to articulate one’s moral position and logical way.
8
NURSE EDUCATION
TODAY
If it is a fundamental
aim of higher education
to create and develop knowledge and to teach others to do likewise, then, I maintain, that this endeavour
must include
moral
education,
and
especially so where the educational goal is to produce competent professionals. If professions claim that their various enterprises require
‘it takes place in the context of people trying to answer criticisms of their character, and in the context
of people trying to justify ways of life . .’ (Putnam 1978, p84)
to other people.
And this, undoubtedly,
to
such
of
an
enquiry
intellectually skilled and mature people, then they need no less morally skilled and mature
courage.
members,
of some complex
The degree
to which a person can be
can be a painful experi-
ence. To expose oneself, as teacher or student, requires
a special
One’s inability to grasp the finer points biochemical
one’s
rational,
the person and some reasonable
and responsible
~~359-361). An autonomous
person
(Kay
1975,
has a secure sense of
unwillingness
process
considered morally mature depends on the degree to which he or she is autonomous, altruistic
usually
be found
become
expert
seen as extraneous
They are rational
willingness obligations
to
discuss
in so far as there is a
reasonably
of interdependent
fessional relationships
personal
and sufficient
abstract moral principles tarian data including
the
moral
and pro-
flexibility to
from a mass of authori-
those offered
by the pro-
fession. Students care
on the path towards one of the health
professions
deveioping revealing objects
may have
a high
degree
a concern
for
and considering
little
difficulty
of moral people
other
in
altruism
rather
than
people’s needs to
They are external
argument
essentially
a self-examination.
the discomfort
altruism which
with a sense alone
coherent courageous
of moral
and
responsibility
In order to avoid
of this learning
experience,
it is
hardly less painful to suggest that one might be content to remain a moral moron. In studying the relevant literature now generally (although
described
as health
ethics), it is remarkable
ethics
that in only a minority of
these texts the word ‘conscience’ index.
in what is care
some cling to the older title of medical appears
in the
I have not found one in 20 years which
In a world where knowledge
rationality,
be
concerned with vital aspects of our very identity and consciousness. It is and must be quite
as such is not necessarily
of autonomy,
moral
can hardly
in the same sense since it is
listed ‘courage’
is the co-existence
to can
have to
of moral perceptions,
and moral
be at least as important as their own. It is vital, however, to remember that the altruistic person a mature moral agent. It
explanation
why not all people
Any examination
independently conduct.
or even
not necessarily
biochemists.
reasoning
guides to ‘good’
to try are
seen as defects of character.
identity and can rely on the validity of his or her and reach a conclusion moral judgments of heteronomous
kind
among its key words.
This is both perplexing
and deeply worrying. that and knowledge
how have brought
us to the brink
destruction,
medical
where
expertise
of nuclear has been
can lead to valid, consistent and moral decisions and morally
and still is used to torture and kill people efficiently, where sick, deprived and destitute
actions.
people
cannot
be adequately
provided
for by
The development of moral courage is not only a legitimate but also a necessary aim of higher
nations which are conquering outer space, and where professions of all kinds observe the inter-
education.
ests of the powerful
Endeavours
to reach
this
aim
in
themselves require a fair amount of courage. A rational dicussion of ‘how to live’ is clearly possible and even necessary. If most people blocked any enquiry should conduct our lives, such notions ality would become meaningless. But moral reasoning Cartesian vacuum,
how we as mor-
does not take place in a
of the powerless,
rather than serve the needs
conscience
and courage
seem
to be of a premium. But as unfounded courage is foolhardy, so are unreasoned convictions dangerous. No student should leave college without a sound foundation for knowing that, knowing how, knowing why and the ability to reason tently.
coherently
and consis-
NURSE EDUCATION
It is my conviction can find the courage conscientious
Edinburgh,
and students
to be and to become
and courageous
This paper Professor
that teachers
professionals.
is based on the lecture
SchrGck at Queen
truly
Margaret
Scotland on 26 November
given by College, 1987.
References Beardshaw V 1981 Conscientious objectors at work: mental hospital nurses - a case study. Social Audit, London Benjamin M and Curtis J 198 1 Ethics in nursing. Oxford University Press, New York Campbell A V 1984’ Moral dilemmas in medicine. Churchill Livingstone, Edinburgh Childress J F 1979 Appeals to conscience. Ethics 89: 31617
TODAY
Downie R S Calman K C 1987 Healthv respect: health care. Faber and Faber, Londbn ’ Etzioni A 1964 Modern organisations. Prentice
9
ethics in Hall,
New lersey Hughe; E C’1963 Professions in - Esland G, Salaman and Speakman M (eds) (1975) People and work.
G
Holmks McDougail/Tie Open U&ersity Press, Edinburgh, ~~248-257 Kay W 1975 Moral education. George Allen and Unwin, London Putnam H 1978 Meaning and the moral sciences. Routledge and Kegan Paul, London Schriick R A 1982 Is health visiting a profession? Health Visitor 55. 3: 104-106 Schrijck R A 1987 Professionalism - a critical examination in - Hockey L (ed) Recent advances in nursing: current issues Churchill Livingstone, Edinburgh, pp 12-24 Veatch R M 1981 A theory of medical ethics. Basic Books Inc Publishers, New York United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1984 Code of professional conduct for the nurse, midwife and health visitor. UKCC, London.
0260 69 17/90/00
Conscience and courage of professional conduct
IO-0003/$10.00
a critical examination
Ruth A Schrbck
The roots of professional power and authority lie in the claim to a specific kind of knowledge, the ‘knowledge that’ and the ‘knowledge how’. These kinds of knowledge are included in the notion of ‘science’. ‘Knowledge why’ - the justification for a professional action - demands a moral argument in terms of what is known and can be done (taking ‘scientific’ knowledge into account) but most importantly asking whether it ought to be done. It is important to ask how a nurse acquires the ‘knowledge why’ and thereby the means to justify his/her conduct in moral terms. This paper considers the norms of professional conduct, the professional mandate and the determination of what is, to the best of the professional’s knowledge and conscience, the right act. The question is raised whether an appeal to the individual conscience can be a reliable guide to a morally justifiable action. An exploration of moral perceptions, moral reasoning and moral argument needs to be part of a professional education which requires a certain kind of courage on part of both teachers and students.
A SPECIAL RESPONSIBILITY It has been suggested that one of the roots of professional authority and power lies in the claim to a specific kind of knowledge which is to be used without discrimination for the benefit of those who are in need of it (Schrock 1982, pp104-105.) While reminding ourselves that the knowledge which professions suggest they have is often not anything as unique, inaccessible or general as the public has been led to believe, common sense would expect that people who
Ruth A Schdck MA PhD DNS(Educ) SRN RMN RNT, Professor of Nursing and Social Sciences, Fachhochschule Osnabriick, Albrechtstrasse 30,450O Osnabriick, Germany (Requests for offprints to RAW Manuscript accepted 1 June 1989
study in a particular field over a number of years ought to know something that others do not know. Personal experience, if nothing else, also tells us that knowledge is indeed power. Anyone who knows little of the workings of a car engine and who ‘needs’ the knowledge which a car mechanic can offer, will be able to attest to his or her vulnerability, or at least to that of their purse. It is self-evident that people can get hurt by the misuse of knowledge which they expected another person to acquire and use for their benefit rather than to their detriment. It is an essential part of higher education, and its main function, to create and develop knowledge, to teach others how to do likewise and how to use knowledge effectively and responsibly. The academic teacher will emphasise such criteria as the
reliability
know,
insist
and
validity
on a balanced
of what
we claim
presentation
to
a.nd 3
4
NURSE EDUCATION
TODAY
intellectual honesty, and even convince the student that it is essential to know what we do not
that all knowledge
is somehow
and derived
‘science’,
know. All these endeavours
perceived are rightly
emphasised
sciences.
throughout the student’s progress towards the chosen goal but are largely restricted to a particular kind of knowledge.
No doubt, irreparable
the property
where
to be synonymous a justification,
is known
and
possibly of
of
‘science’
is
with the empirical
An answer to the question
constitute what
from
what
‘why’ would in terms
can
be
of
done.
However,
what is possible in terms of (narrowly
scientific)
knowledge
harm could befall a patient who relied on the nurse’s knowledge of passing a tube into his
same as what ought to be done.
In the offered
stomach so that he could receive nourishment
example,
to pass a tube
a safe and adequate unable to breathe trachea
way and then found himself
as the tube had ended up in his
due to the practitioner’s
Of course,
in
the nurse
well how to perform
ignorance.
this procedure,
very
and the skill
required may have been founded on sound, systematic knowledge and both theoretical and He could
practical
understanding.
negligent
or might have allowed his knowledge
to be used for evil purposes torture.
like punishment
nurse was in fact knowledgeable justify would
have been or
If the latter were the case, that is, the
or by adopting
but negligent,
values which may in his mind
punishments
or torture,
be no use in increasing
clearly
there
his knowledge
how
to perform this procedure. Neither would there be much point in adding to his knowledge that the relevant particular
anatomy structures
and physiology and processes.
whether
a degree
justified All
of negligence
professions
have
create and develop practical knowledge titioner
or punishment
1987, pp8-21)?
the
responsibility
relevant theoretical which permits the
to utilise in his work whatever
to and prac-
can be
known at any given time; but when we add that what he knows and can do must be used only to the patient’s
or client’s
benefit,
we express
a
moral principle. A special responsibility is laid on the profession collectively and carried by each practitioner individually which requires certain kinds of conduct
and prohibits
through
trachea
and cause fluid to pass
it. It certainly can be done but few of us that it ought
to be done.
Know-
ledge of what ought to be done is only partially derived
from
theoretical
and
practical
know-
ledge. We must develop and accept ‘A view of knowledge the sphere
that acknowledges
of knowledge
sphere of ‘science’.
is wider
(as)
or of science.’
It is pertinent nurse
the
. . a. . . necessity, if
we are to arrive at a sane and human ourselves
that
than
(Putham
view of
1978, p5)
to ask in what way the individual
acquires
this
wider
knowledge
and
thereby the means to justify his conduct in moral terms, that is, as being right in addition to being possible.
in
by these or any other means are ever
(Downie & Calman
into a person’s
possible
consist of Where,
knowledge that and knowledge how could we look for an answer to the moral questions and torture
it is obviously
would accept
may have known
and skills is not at all the
others.
Knowledge why a nurse or any other health care worker may choose to do one thing rather than another includes knowledge that and knowledge how but it is a seriously mistaken view
NORMS OF PROFESSIONAL CONDUCT Sociologists
tell us that one of the characteristics
of a profession
is its authority
ards of behaviour cating
disputes
regulation
in setting
for its members about
their
conduct.
This
in the context of a professional
based on a number
stand-
and in adjudiself-
ethic is
of claims which include that
the profession: 1) is entitled principles
to generate its own norms and governing correct professional
conduct 2) is the only body having knowledge of what is morally required for its members 3) is the only group capable of adjudicating moral disputes related to professional conduct 4) has a responsibility for discipline on its members
imposing
moral
NURSE EDUCATION
5) is empowered to articulate its own set of moral standards usually in the form of a code.
ually exercise
that
‘The existence
of a code or set of standards a characteristic group,
is
that it can
be used to resolve disputes over whether in an occupational
those
such as accountants
or appraisers or archivists, can be termed professionals.’ (Veatch 198 1, ~83)
real
which uses a series of characteristics
that established
professions
for other
aspiring
status
to professional Suffice
An examination
argument
1987,
is a circular
of a somewhat
of historically
like medicine
(Schrock
it to say that by any standards
of logic the underlying concept
occupations
pre-eminent
idealised
professions
and law results in a set of formal
characteristics.
These
are by no means
realised
in everyday practice even by the established professions. Nonetheless, they are meant to provide a meaningful set of criteria by which to label
occupational
(Schrock This
groups
as
professions
1982). gets us no further
than
noting
profession is what I say it is. Rather more important questions the above claims to a professional determination constitutes
right and wrong.
question
must
professions conduct
by a profession surely
the professional
arise from
ethic with the
for itself of what The
be who
in general
which govern
most obvious
has authorised
to establish
principles
the relationship
worker
that a
of
between
and his or her clients?
To what extent, if any, should the general public be bound by the opinions of the council of a professional
body?
Hughes
describes
The central justification
for this mandate
ledged contract
or bargain
and equitable trol granted
benefits. to the
lies in
but acknow-
between
the profes-
resulting
in mutual
The autonomy and conprofessions over their
by the wider society
are part of this
bargain by which the professions
in turn guaran-
tee to the community
service of high
an expert
standard and by which they are compensated for the risk-taking which is inherent in the serious consequences or negligently
that a professional task inexpertly performed may have.
‘The issue of risk-taking the argument attendant
is a central
for professional
autonomy
of
point in
status with its
decision
making.
Therefore decisions need to be informed by expert knowledge with the ultimate justification for a professional
act that it is. to the best
of
knowledge
the
professional’s
science,
the right act.’ (Schrock
Although
there
are weak points
tionalist argument where
(Schrock
moment
and
in this func-
which I have examined 1987),
let us accept
this notion of a social contract
the professions
con-
1987, ~13)
and society.
Its essential
else-
for
the
between feature
that the privileges and power gained are necessary for the professional in order to use his or her expertise all members
unhindered
and to the benefit
of the community
expresses
which many of us would wish to see realised the greatest
of
an ideal to
possible extent. Neither would many of the
public
find
anything
in the moral principles
really
articulated
in professional codes of conduct. However, the decision of what is ‘to the best of the professional’s knowledge and conscience, the right
MANDATE
one of the mainsprings
to
. .’ (Hughes
the idea that there is an unwritten
objectionable
profession’s authority as the ‘professional date’ in the following terms:
do
1971, p298)
members
THE PROFESSIONAL
(presuming)
tell society what is good and right.
members
are believed to poss-
ess, as a set of criteria ~~12-15).
. . . (and) . . . individ-
sions and society in general
This is not the place to examine in detail the fundamental fallacy of the ‘trait’ or ‘inventory’ approach
mandate
a licence to do things others
not do (as well as) collectively
seen as so essential
one.
‘Professions, perhaps more than other kinds of occupation . . . claim a broad legal, moral and intellectual
Veatch observes
5
TODAY
of a man-
act’ can only ever be an individual one. The code of professional conduct for the nurse, midwife and health visitor published by
6
NURSE EDUCATION
the
United
TODAY
Kingdom
Nursing,
Midwifery
stresses,
for example,
Central
and Health
Council Visiting
privileged residence
allowed
obviously
tells them
relationship and of the
to their
property,
or workplace.’
that what they
did was wrong. Appeals to conscience
with patients/clients
access
conscience
the need to
‘Avoid any abuse of the privileged which exists
for
(1984)
subjective.
They
ment of rightness by
personal
authority
are clearly personal and
are founded
on a prior judg-
and wrongness
sanction
(Benjamin
rather
& Curtis
and motivated than
external
198 1, p96).
The person who feels guilty and who has a bad
This clearly does not tell the nurse what to do. The decision not to misappropriate a patient’s
conscience
belongings
maxim ‘don’t drink and drive’ as right. To put it
must be made by the individual nurse
in her own ‘knowledge
and conscience’
that this
is the right act which finds its justification only in the above statutory
another
1981, p96).
that exhorts
us not to
steal.
and driving has before
this
action
way - our conscience
of rightness
eral moral commandment
of
accepted
the
does not tell us
what is right or wrong, ‘it mustfollow ajudgment
by her
articulated
after drinking
commission
body but also in the gen-
principle
professional
not
the
or wrongness’
(Benjamin
& Curtis
Campbell (1984, ~23) has succinctly summarised this dilemma. ‘It seems that conscience is a powerful force in controlling the actions of most individuals . . .
THE APPEAL TO CONSCIENCE An explicit conscience
appeal
to the professional
is an integral
of the professional’s ~76) observes
person’s
part of the justification
autonomy.
Etzioni
(1964,
that
‘Students of the professions have pointed out that the autonomy granted to the professionals who are basically responsible consciences fessional
. . . is necessary
to their
for effective
pro-
work.’
The notion that the individual’s consicence is the final arbiter in deciding what it is right or wrong to do in a professional glance to be persuasive. only the individual
context
seems
at first
Having insisted that it is
who can and, indeed,
must
But although powerful, it may not always be right . . . After all, if everyone’s conscience always gave totally correct statements of the right actions in situations,
not two consciences
would ever differ. Yet, unless we support that everyone with different views from our own is either
totally ignorant
pulous, genuine
or completely
we know that disagreements
the guidance
of my conscience
may be right
for me, but not right for somebody Apart
from
the fact that
unscru-
there can be many of conscience. Thus
‘following
else.’ our con-
science’ may leave us with a disturbing sense of the relativity of all values, it would obviously be impractical
to provide
a coherent
service
for
decide what, to the best of his or her conscience,
people on this basis. There is a danger, in my view, that the uncritical appeal to one’s con-
the right act is, it then seems inescapable that it is our own conscience which directs our actions. The individual conscience as a guide to moral
science may on occasion be a form of self-indulgence. The values which we have internalised become an important constituent part of our
action may, however,
personality, contribute inform our self-esteem.
present
us with a difficult
problem. Our own experiences show that not everyone’s conscience directs its owner in the same way. Some people’s
conscience
tells them
that it is quite all right to drink and drive or to cheat the Inland Revenue. Other people, having driven home after a party or having failed to declare
an item of income,
feel guilty.
Their
is primarily
to our sense of self and An appeal to conscience
based on a desire to preserve
one’s
integrity or wholeness as a person (Benjamin & Curtis 198 1, p95). ‘I could not live with myself, we say, or ‘I could not face myself, when we maintain a certain stance as a matter of conscience. Really?
NURSE EDUCATION
Who does not recall some incidence hood, the first conscious
in child-
lie, a few stolen apples
or an act of disobedience
which
caused
the
perpetrator a truly sleepless night because of the loud and clear voice of conscience? Somehow, lying
becomes
progressively
easier
as we get
leagues
or the
especially
fear
of student Beardshaw’s
standing
their conscience
occasionally
and regretfully aware of a certain loss of moral sensitivity, we manage to live reasonably well with ourselves moral
most of the time. This process of
desensitisation
is, as we well know, also
part of the novice’s
socialisation
sion. It is eloquently
expressed
nurse
in an example
into a profesby a psychiatric
cited by Campbell
(1984,
‘ . . the trouble
is . . . that one tends
respond immediately
not to
to one’s sense that wrong
is being done. Thus the dictates of conscience become
less clear and are eventually
the extent that self interest over patient interest.’ When
objectors
it is in our
overcome
interest,
remain undisturbed ness and thought
it seems,
care
of mentally
appeal
to it in order
to
1979, ~316).
conclusion
people
set a high
turbed.
In a conflict of consciences,
at a searching
must be that
value on remaining
examination
expressed
if they complained
told them
of what
to be wrong
ill people.
in
‘Conscientious
One
in the
comment
is
typical of many. ‘My name would be blackened tainly I would be victimised, difficult
to get promotion
complaint
and most cer-
and (it would be)
- if I had to make a
of any sort.’ (Beardshaw
anticipated
unsettling
or
experiences
actual were
198 1, ~35).
disturbing clearly
and
weighed
against the distress caused by a guilty conscience. In most cases, nurses and eventually
find it easier to bear with
silence their conscience.
we can
about (our) own acts and their
A not unreasonable
participated of
on the one
in ‘. . . a mode of conscious-
value or disvalue’ (Childress
of
takes precedence
the pangs of conscience
hand or, on the other,
stifled to
out for fears
at work’ in mental hospitals
These
Pl9)
singled Nurses’
who
nurses
( 198 1) study
a fear of reprisals,
Although
duties.
being labelled as a trouble-maker by colleagues are very real indeed. More than three-quarters
older, stolen apples turn into expected perks of the job and disobedience becomes the virtue of up for oneself.
of being
unpleasant
7
TODAY
undis-
any attempt
of the values which
have directed
our ‘conscientious’
be disturbing.
A sense of uncertainty
response
must
and unease
is inevitable
when one permits possibly long held
convictions
to be questioned.
An apprehension
that one might not be able to justify
one’s moral
A CERTAIN KIND OF COURAGE It would
be easy
unwillingness professionals which
to attribute
of nurses to confront
they experience
way to a lack of personal
the
apparent
and of many other the moral dilemmas in a more courage.
constructive However,
this
seems to me patently unjust. We would not accuse a person who does not cross the Atlantic in a sailing boat of a lack of courage,
if they had
no knowledge
no skill in
of navigation
and
sailing a boat. If such an attempt
were made by
ignorant
we would call
and unskilled
persons
except by an embarrassing cliche may unease. The individual add to one’s undoubtedly reacts to this possibility of being disturbed by trying to avoid a genuine examin-
them stupid and foolhardy. I would not consider it cowardly to avoid a disputation with a nuclear
ation of the issues involved.
Clearly we expect that physical and intellectual courage must be based on sound knowledge
stance
consistent
appeal
A determined
to conscience
achieves
and just
physicist,
if I had no knowledge
that. Similarly, a bad conscience is a disturbing and unsettling experience but so are many other
accompanied
experiences
in a coherent
like being
rejected
by one’s
col-
of physics and
knew myself to be a poor debater.
by appropriate
skills.
Similarly,
moral courage requires a rational foundation and the ability to articulate one’s moral position and logical way.
8
NURSE EDUCATION
TODAY
If it is a fundamental
aim of higher education
to create and develop knowledge and to teach others to do likewise, then, I maintain, that this endeavour
must include
moral
education,
and
especially so where the educational goal is to produce competent professionals. If professions claim that their various enterprises require
‘it takes place in the context of people trying to answer criticisms of their character, and in the context
of people trying to justify ways of life . .’ (Putnam 1978, p84)
to other people.
And this, undoubtedly,
to
such
of
an
enquiry
intellectually skilled and mature people, then they need no less morally skilled and mature
courage.
members,
of some complex
The degree
to which a person can be
can be a painful experi-
ence. To expose oneself, as teacher or student, requires
a special
One’s inability to grasp the finer points biochemical
one’s
rational,
the person and some reasonable
and responsible
~~359-361). An autonomous
person
(Kay
1975,
has a secure sense of
unwillingness
process
considered morally mature depends on the degree to which he or she is autonomous, altruistic
usually
be found
become
expert
seen as extraneous
They are rational
willingness obligations
to
discuss
in so far as there is a
reasonably
of interdependent
fessional relationships
personal
and sufficient
abstract moral principles tarian data including
the
moral
and pro-
flexibility to
from a mass of authori-
those offered
by the pro-
fession. Students care
on the path towards one of the health
professions
deveioping revealing objects
may have
a high
degree
a concern
for
and considering
little
difficulty
of moral people
other
in
altruism
rather
than
people’s needs to
They are external
argument
essentially
a self-examination.
the discomfort
altruism which
with a sense alone
coherent courageous
of moral
and
responsibility
In order to avoid
of this learning
experience,
it is
hardly less painful to suggest that one might be content to remain a moral moron. In studying the relevant literature now generally (although
described
as health
ethics), it is remarkable
ethics
that in only a minority of
these texts the word ‘conscience’ index.
in what is care
some cling to the older title of medical appears
in the
I have not found one in 20 years which
In a world where knowledge
rationality,
be
concerned with vital aspects of our very identity and consciousness. It is and must be quite
as such is not necessarily
of autonomy,
moral
can hardly
in the same sense since it is
listed ‘courage’
is the co-existence
to can
have to
of moral perceptions,
and moral
be at least as important as their own. It is vital, however, to remember that the altruistic person a mature moral agent. It
explanation
why not all people
Any examination
independently conduct.
or even
not necessarily
biochemists.
reasoning
guides to ‘good’
to try are
seen as defects of character.
identity and can rely on the validity of his or her and reach a conclusion moral judgments of heteronomous
kind
among its key words.
This is both perplexing
and deeply worrying. that and knowledge
how have brought
us to the brink
destruction,
medical
where
expertise
of nuclear has been
can lead to valid, consistent and moral decisions and morally
and still is used to torture and kill people efficiently, where sick, deprived and destitute
actions.
people
cannot
be adequately
provided
for by
The development of moral courage is not only a legitimate but also a necessary aim of higher
nations which are conquering outer space, and where professions of all kinds observe the inter-
education.
ests of the powerful
Endeavours
to reach
this
aim
in
themselves require a fair amount of courage. A rational dicussion of ‘how to live’ is clearly possible and even necessary. If most people blocked any enquiry should conduct our lives, such notions ality would become meaningless. But moral reasoning Cartesian vacuum,
how we as mor-
does not take place in a
of the powerless,
rather than serve the needs
conscience
and courage
seem
to be of a premium. But as unfounded courage is foolhardy, so are unreasoned convictions dangerous. No student should leave college without a sound foundation for knowing that, knowing how, knowing why and the ability to reason tently.
coherently
and consis-
NURSE EDUCATION
It is my conviction can find the courage conscientious
Edinburgh,
and students
to be and to become
and courageous
This paper Professor
that teachers
professionals.
is based on the lecture
SchrGck at Queen
truly
Margaret
Scotland on 26 November
given by College, 1987.
References Beardshaw V 1981 Conscientious objectors at work: mental hospital nurses - a case study. Social Audit, London Benjamin M and Curtis J 198 1 Ethics in nursing. Oxford University Press, New York Campbell A V 1984’ Moral dilemmas in medicine. Churchill Livingstone, Edinburgh Childress J F 1979 Appeals to conscience. Ethics 89: 31617
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Downie R S Calman K C 1987 Healthv respect: health care. Faber and Faber, Londbn ’ Etzioni A 1964 Modern organisations. Prentice
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ethics in Hall,
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Holmks McDougail/Tie Open U&ersity Press, Edinburgh, ~~248-257 Kay W 1975 Moral education. George Allen and Unwin, London Putnam H 1978 Meaning and the moral sciences. Routledge and Kegan Paul, London Schriick R A 1982 Is health visiting a profession? Health Visitor 55. 3: 104-106 Schrijck R A 1987 Professionalism - a critical examination in - Hockey L (ed) Recent advances in nursing: current issues Churchill Livingstone, Edinburgh, pp 12-24 Veatch R M 1981 A theory of medical ethics. Basic Books Inc Publishers, New York United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1984 Code of professional conduct for the nurse, midwife and health visitor. UKCC, London.