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Independence and free will needed to be morally responsible
AUGUST 1984. VOL 40. NO 2
AORN J O U R N A L
Ethics Independence and free will needed to be morally responsible
W
hat is taught as nursing ethics has changed greatly in the last decade. New graduates and experienced practitioners often have difficulty communicating about perceived ethical dilemmas. New graduate nurses may be naive about their impact on ethical decision making, given institutional constraints. Experienced practitioners may be threatened by recent definitions of ethical responsibilitiesand view the new graduates as t w idealistic. Moral responsibility for the nurse in any situation is tempered by many factors.
The Logic of Moral Responsibility
F
or what and to whom is one accountable summarizesthe concept of moral responsibility. Logic is the science of correct reasoning, while moral responsibility refers to one's obligation or duty. Stated simply, moral responsibility is that for which one is morally answerable. Responsibility has many meanings. One type of responsibility is role responsibility. By choosing the profession of nursing, the nurse freely assumes the duties and obligations inherent to nursing. Full moral responsibility requires free will; it requires that an act be voluntary. Any compulsion or coercion decreases the extent of moral responsibility proportionately. Another element affecting the voluntary nature of an action is ignorance. Only actions performed freely are worthy of praise or blame. "Although nurses usually have direct respon262
sibility for the care of patients and the implementation of therapy in hospital settings, they have relatively little influence in decision making."' Legally, nurses are dimtly and independently responsible for their actions. In the moral realm, however, the nurse is subject to rules and policies that often compromise the extent of free will behind actions. All decision making, including ethical decision making, in most hospitals' bureaucratic settings rarely results from totally independent thought. Many nurses question whether they can be ethical or ethically responsible in today's complex health care system. So establishing moral responsibility or accountability and feeling responsible for one's actions can be difficult. The nature of a health care institution is such that on many occasions just about everyone can be said to share the accountability for an action. Thus, everyone is to be blamed or praised. In practice, this usually means that no one is held morally accountable . . . Nothing threatens real morality in health care more than the doctrine of nonaccountability. or the Rita J Payton, RN, DA. is professor and assistant director at the University of Northern Colorado (UNC) School of Nursing. Greeley. She earned her nursing degreefrom St Mary's College. Notre Dame, Ind. and her master's degree in nursing education with a specialty in pediatrics/ram Indiana University, Bloomington. Pavton has a doctor of arts in bioethics education from UNC, and served on the American Nurses' Association Committeeon Ethicsfor six years until December 1982.
AUGUST 1984. VOL 40, NO 2
AORN J O U R N A L
In reality, a nurse often feels a duty to act before understanding the reasons for the feelings. belief. that liability is the exclusive test of moral accountability.* Hans Jonas has written extensively about the need to revise an ethics of responsibility to align it with current dilemma^.^ A useful concept of moral responsibility matches the possible types and powers of actions. Jonas believes we must differentiate between the objective and subjective components of responsibility. The objective component is based on reason, while the subjective portion is based on emotion. Logically, the validity of obligation comes first, with the subjective portion of responsibility or the responding emotion following. In reality, the nurse often feels a duty to act before consciously understanding the feelings. In other words, the subjective portion of responsibility is what usually moves the will to act. Nurses must be concerned with the objective c o m p o n e n t 4 rational ground of responsibility. These three general conditions must be present to establish true objective responsibility causal power 0 control 0 knowledge. For causal power to exist, the nurses’s action must have an impact on the solution of an ethical dilemma. To control actions, they must be voluntary. Having knowledge is judged by the nurses’ ability to foresee the consequences.
Formal and Substantive Responsibility
0
bjective responsibilitycan be viewed in two senses-formal and substantive responsibility: Formal responsibility means the nurse actually acted. The nurse must act to be assigned moral responsibility. Remember, however, that the nature of the nurse’s consent is not determined by declaring formal responsibility exists. Substantive responsibility 264
must also be present for true moral responsibility to exist. When the nurse believes a patient situation requires nursing action, she assumes substantive responsibility. The philosophy of substantive responsibility may be clarified by this example. The nurse on the surgical floor is talking with a patient scheduled to have surgery the next morning. The physician has obtained a signature on the surgical consent form and has told the nurse that the proposed procedure has been explained well to the patient. In talking with the patient, however, the nurse realizes that the patient has no meaningful understandingof what the proposed surgical procedure might entail. The nurse feels she ought to do something because of the patient’s obvious lack of knowledge. She knows that, even though the patient signed the consent form, informed consent is not present. She also knows she has the power to take action that will fleet the situation. She feels obligated to the patient and is therefore obliged to act. This is substantive responsibility. For nurses, the relationship between power of free will and moral responsibility is the source of increased concern today. One can only be responsible-in the formal sense-when one has power. What happens when power is diffised via committee decision or bureaucratic structure? In these situations, determining who has the true source of power, in terms of formal responsibility, is difficult. At the same time, individuals still feel responsible in terms of substantive responsibility. It is important to track the nature of this dilemma. The dilemma is that the nurse feels substantively responsible but is not able to respond formally. Shared power constrains shared decision action. Thus, the complexity of decision making limits personal power. In the end, the action often differs from personal committed power. The greatest danger is that after repeated ex-
AORN JOURNAL
AUGUST 1984, VOL 40. N O 2
periences with resultant action differing from personal committed power, the nurse’s sensitivity to feelings of responsibility decrease. This reaction is necessary to survive. In surviving, nurses often feel guilt stemming from a sense of obligation without the accompanying power. It appearsthat nurses are exhibiting many behavioral manifestations of guilt. Some nurses have insomnia, symptoms associated with anxiety, are depressed or use the defense mechanism of rationalization and avoidanceto an extreme. Could not a significant portion of the burnout syndrome relate to the ultimate avoidancebehavior of nurses experienc-
ing extreme guilt because of self-perceived transgressions of their moral-ethical code? RITA J PAYTON, RN Notes 1. Margaret O’Brien Steinfels, “Ethics, education, and nursing practice,” The Hustings Center Report 7 (August 1977) 20-21. 2. Vincent Barry, Moral Aspects of Health Care (Belmont, Calif: Wadsworth Publishing Company,
1982) 9.
3. Hans Jonas, “The concept of responsibility:An inquiry into the foundations of an ethics for our age” in Knowledge, Value and Belief, ed. Tristram H Englehardt, Daniel Callahan (New York Hastings-onHudson, 1977) 169-198.
Congress Tape Sales Result in Contribution
Patricia Meyer and Clifford Jordan make a presentation to William Fitzmaurice of the American Cancer Society. Meyer Communication Corp, the company that sold tapes of Congress sessions, donated a percentage of its earnings to the American Cancer Society. William Fitzmaurice, chairman of the Public Information Committee for the Colorado division of the American Cancer Society, communicated to
Patricia Meyer, executive vice-president of Meyer Communication, and Clifford Jordan, executive director of AORN, that the generous support would be used wisely for the programs of research, education, patient service, and rehabilitation. The donation exceeded $625.
265
AORN J O U R N A L
Ethics Independence and free will needed to be morally responsible
W
hat is taught as nursing ethics has changed greatly in the last decade. New graduates and experienced practitioners often have difficulty communicating about perceived ethical dilemmas. New graduate nurses may be naive about their impact on ethical decision making, given institutional constraints. Experienced practitioners may be threatened by recent definitions of ethical responsibilitiesand view the new graduates as t w idealistic. Moral responsibility for the nurse in any situation is tempered by many factors.
The Logic of Moral Responsibility
F
or what and to whom is one accountable summarizesthe concept of moral responsibility. Logic is the science of correct reasoning, while moral responsibility refers to one's obligation or duty. Stated simply, moral responsibility is that for which one is morally answerable. Responsibility has many meanings. One type of responsibility is role responsibility. By choosing the profession of nursing, the nurse freely assumes the duties and obligations inherent to nursing. Full moral responsibility requires free will; it requires that an act be voluntary. Any compulsion or coercion decreases the extent of moral responsibility proportionately. Another element affecting the voluntary nature of an action is ignorance. Only actions performed freely are worthy of praise or blame. "Although nurses usually have direct respon262
sibility for the care of patients and the implementation of therapy in hospital settings, they have relatively little influence in decision making."' Legally, nurses are dimtly and independently responsible for their actions. In the moral realm, however, the nurse is subject to rules and policies that often compromise the extent of free will behind actions. All decision making, including ethical decision making, in most hospitals' bureaucratic settings rarely results from totally independent thought. Many nurses question whether they can be ethical or ethically responsible in today's complex health care system. So establishing moral responsibility or accountability and feeling responsible for one's actions can be difficult. The nature of a health care institution is such that on many occasions just about everyone can be said to share the accountability for an action. Thus, everyone is to be blamed or praised. In practice, this usually means that no one is held morally accountable . . . Nothing threatens real morality in health care more than the doctrine of nonaccountability. or the Rita J Payton, RN, DA. is professor and assistant director at the University of Northern Colorado (UNC) School of Nursing. Greeley. She earned her nursing degreefrom St Mary's College. Notre Dame, Ind. and her master's degree in nursing education with a specialty in pediatrics/ram Indiana University, Bloomington. Pavton has a doctor of arts in bioethics education from UNC, and served on the American Nurses' Association Committeeon Ethicsfor six years until December 1982.
AUGUST 1984. VOL 40, NO 2
AORN J O U R N A L
In reality, a nurse often feels a duty to act before understanding the reasons for the feelings. belief. that liability is the exclusive test of moral accountability.* Hans Jonas has written extensively about the need to revise an ethics of responsibility to align it with current dilemma^.^ A useful concept of moral responsibility matches the possible types and powers of actions. Jonas believes we must differentiate between the objective and subjective components of responsibility. The objective component is based on reason, while the subjective portion is based on emotion. Logically, the validity of obligation comes first, with the subjective portion of responsibility or the responding emotion following. In reality, the nurse often feels a duty to act before consciously understanding the feelings. In other words, the subjective portion of responsibility is what usually moves the will to act. Nurses must be concerned with the objective c o m p o n e n t 4 rational ground of responsibility. These three general conditions must be present to establish true objective responsibility causal power 0 control 0 knowledge. For causal power to exist, the nurses’s action must have an impact on the solution of an ethical dilemma. To control actions, they must be voluntary. Having knowledge is judged by the nurses’ ability to foresee the consequences.
Formal and Substantive Responsibility
0
bjective responsibilitycan be viewed in two senses-formal and substantive responsibility: Formal responsibility means the nurse actually acted. The nurse must act to be assigned moral responsibility. Remember, however, that the nature of the nurse’s consent is not determined by declaring formal responsibility exists. Substantive responsibility 264
must also be present for true moral responsibility to exist. When the nurse believes a patient situation requires nursing action, she assumes substantive responsibility. The philosophy of substantive responsibility may be clarified by this example. The nurse on the surgical floor is talking with a patient scheduled to have surgery the next morning. The physician has obtained a signature on the surgical consent form and has told the nurse that the proposed procedure has been explained well to the patient. In talking with the patient, however, the nurse realizes that the patient has no meaningful understandingof what the proposed surgical procedure might entail. The nurse feels she ought to do something because of the patient’s obvious lack of knowledge. She knows that, even though the patient signed the consent form, informed consent is not present. She also knows she has the power to take action that will fleet the situation. She feels obligated to the patient and is therefore obliged to act. This is substantive responsibility. For nurses, the relationship between power of free will and moral responsibility is the source of increased concern today. One can only be responsible-in the formal sense-when one has power. What happens when power is diffised via committee decision or bureaucratic structure? In these situations, determining who has the true source of power, in terms of formal responsibility, is difficult. At the same time, individuals still feel responsible in terms of substantive responsibility. It is important to track the nature of this dilemma. The dilemma is that the nurse feels substantively responsible but is not able to respond formally. Shared power constrains shared decision action. Thus, the complexity of decision making limits personal power. In the end, the action often differs from personal committed power. The greatest danger is that after repeated ex-
AORN JOURNAL
AUGUST 1984, VOL 40. N O 2
periences with resultant action differing from personal committed power, the nurse’s sensitivity to feelings of responsibility decrease. This reaction is necessary to survive. In surviving, nurses often feel guilt stemming from a sense of obligation without the accompanying power. It appearsthat nurses are exhibiting many behavioral manifestations of guilt. Some nurses have insomnia, symptoms associated with anxiety, are depressed or use the defense mechanism of rationalization and avoidanceto an extreme. Could not a significant portion of the burnout syndrome relate to the ultimate avoidancebehavior of nurses experienc-
ing extreme guilt because of self-perceived transgressions of their moral-ethical code? RITA J PAYTON, RN Notes 1. Margaret O’Brien Steinfels, “Ethics, education, and nursing practice,” The Hustings Center Report 7 (August 1977) 20-21. 2. Vincent Barry, Moral Aspects of Health Care (Belmont, Calif: Wadsworth Publishing Company,
1982) 9.
3. Hans Jonas, “The concept of responsibility:An inquiry into the foundations of an ethics for our age” in Knowledge, Value and Belief, ed. Tristram H Englehardt, Daniel Callahan (New York Hastings-onHudson, 1977) 169-198.
Congress Tape Sales Result in Contribution
Patricia Meyer and Clifford Jordan make a presentation to William Fitzmaurice of the American Cancer Society. Meyer Communication Corp, the company that sold tapes of Congress sessions, donated a percentage of its earnings to the American Cancer Society. William Fitzmaurice, chairman of the Public Information Committee for the Colorado division of the American Cancer Society, communicated to
Patricia Meyer, executive vice-president of Meyer Communication, and Clifford Jordan, executive director of AORN, that the generous support would be used wisely for the programs of research, education, patient service, and rehabilitation. The donation exceeded $625.
265