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Principles and Methods of Ethical Decision Making in Critical Care Nursing
I
os99-5885/97 $0.00 + .20
Ethical Decision Making in the
Critical Care Patient
Principles and Methods of Ethical Decision Making in Critical Care Nursing Nancy S. Jecker, PhD
Is it ethical to use morphine drips not only to alleviate suffering but also to speed up the process of dying? What should be done when families insist on excessive and burdensome treatments that members of the health care team believe are not in the patient's best interest? Are cost-limiting measures ever justified if more expensive treatments would offer a potentially greater benefit or lesser risk to the patient? Should nurses participate in "slow codes" if they think a patient should be allowed to die but no do-not-resuscitate order has been written by the attending physician? Is withdrawal of nutrition and hydration similar to withdrawal of other medical interventions, such as respirators and dialysis machines, or do food and fluids carry deeper social meanings related to human caring and nurturance? Do you have a decision-making process for dealing with such ethical dilemmas? Or do you find yourself often making ethical decisions in a haphazard way, pushed in one direction or another by the pressures of time,
From the Department of Medical Histoiy and Ethics, University of Washington School of Medicine, Seattle, Washington
place, and circumstance? One of the challenges critical care nurses face is to function as effective moral agents in situations such as those in which decisions must be made quickly; when one's freedom and authority are constrained; when patients are unable to communicate effectively; when medical specialists tend to focus on discrete factual outcomes, often neglecting the patient's overall well-being; and when the pervasiveness of technology can encourage impersonal, efficiency-oriented interactions. These unique circumstances of critical care nursing make it all the more imperative that nurses consider in advance the ethical values at stake in clinical decisions, and hone skills of ethical decision making.
Principles of Health Care Ethics One approach to practical, ethical decision making in nursing directs attention to general ethical principles and argues that these principles represent the "common morality" shared by members of society.4 According to this approach, nurses ought to weigh such common values critically in making health care deci-
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 9 /Number 1 I March 1997
29
30
JECKER
sions. Among the ethical principles most frequently cited are autonomy, beneficence, nonmaleficence, and justice. Autonomy calls for respecting competent patients' choices and actions, even when these conflict with nurses' or others' perceptions of patients' best interests. Specifically, the principle of autonomy relates to the nurse's duty to know and advocate for the competent patient's considered decisions. It requires nurses to engage patients in conversations about their values and beliefs, and to assist patients by sharing information, answering questions, offering recommendations, minimizing environmental stressors, and facilitating communication among patients and other members of the health care team. 20 Both the American Nurses' Association (ANA)2 and The American Association of Critical Care Nurses1 regard patient advocacy and respect for patients' choices as an integral part of nursing practice. According to the ANA Code for Nurses, 2 "Whenever possible, clients should be fully involved in the planning and implementation of their own health care. Each client has the moral right to determine what will be done with his/her person; receive information necessary for making informed judgments; to be told the possible effects of care; and decide to accept, refuse, or terminate treatment." The principle of beneficence, by contrast, emphasizes that "the nurse's primary commitment is to the health, welfare, and safety of the client."3 This principle focuses attention on the consequences of nursing actions, and underscores that one of the central goals of nursing is to help the patient. In the critical care setting, health care providers can readily lose sight of the overall benefit or burden of treatment and focus more narrowly on producing discrete physiologic effects on body parts of organ systems. 21 Nursing benefits the patient as a person only when health professionals distinguish between effects, which are physiologic changes to the patient's body, and benefits, which refer to effects that the person can appreciate as good.
Nonmaleficence relates to the nurse's duty to avoid harming the patient. As Jameton10 notes, "Taken literally this principle would be impossible to follow in practice, since only the simplest forms of treatment do no harm." Instead, the requirement to do no harm asks one to consider whether or not the pain and discomfort that medical interventions cause are, on balance, outweighed by benefits patients receive. The principle of nonmaleficence has a long history in nursing. The nineteenth-century Florence Nightingale Pledge includes the promise to "abstain from whatever is deleterious and mischievous . . . and devote myself to the welfare of those committed to my care."8 A final principle, the principle of justice, relates to the nurse's duty to treat similar patients similarly. In its most general form, justice requires avoiding discrimination against patients on the basis of morally arbitrary features, such as age, sex, perceived social worth, or cultural/ethnic background. Thus a nurse who shows a lack of regard for a patient because he or she is poor and homeless behaves unjustly by failing to give the patient the respect deserved.12 Justice also refers to the more specific problem of distributing limited resources. In the health care setting, distributive justice concerns the question, What health care resources are due or owed to persons in a context of resource scarcity?16 For example, it might be claimed that patients with similar health care needs are owed equal access to health care, that patients deserve whatever services they are able to pay for, or that public health care dollars are owed first to persons who make the greatest social contributions. Questions of distributive justice may pose ethical conflicts for nurses when rationing of scarce resources interferes with advocating for the best interests of individual patients. 13• 14
Critique of Principlism The above framework, comprised of the ethical principles of autonomy, beneficence, non-
ETHICAL DECISION MAKING IN CRITICAL CARE NURSING
maleficence, and justice, is intended to assist with ethical decision making by calling attention to the morally relevant values at stake. On some accounts, the four principles offer ethical backing for general clinical rules and practices. For example, the ethical rule requiring providers to obtain patients' informed consent to treatment may be justified by appealing to the ethical principle of respect for the patient. The practice of withholding or withdrawing futile and burdensome interventions from dying patients may be supported by appealing to the ethical principle of nonmaleficence. This approach to ethical decision making, which has been referred to (originally by its critics7) as "principlism," is invoked widely, appearing both in the literature of health care ethics and in the practice of clinical ethics consultation. It is not free of criticism, however. Within nursing, critics of principlism charge that nurses and patients are ill served by rule-governed behavior. Thus, Benner5 argues that although the novice nurse appeals to principles to resolve nursing dilemmas, expert nurses develop critical judgment and practical experience that enable them to apply case-based critical analysis. She explains that "the rule-governed behavior typical of the novice is extremely limited and inflexible. The heart of the difficulty lies in the fact that since novices have no experience of the situation they face, they must be given rules to guide their performance." 5 By contrast, expert nurses have an enormous range of prior case experiences that enable them to make the right decision in a given situation. For the expert nurse, says Benner, analytic principles have only limited relevance, applying only to novel situations in which the nurse lacks prior experience. In response to this criticism, it can be said that even if resorting to principles to make clinical decisions is unnecessary in situations of moral clarity, ethical principles remain useful in many other cases. As the questions raised at the outset of this article suggest, nurses frequently encounter situations in which they are uncertain
31
about what action to take, or in which members of the health care team disagree about the best course of action. In such instances, identifying the underlying values at stake leads to a more thoughtful resolution of the case. Critics of principlism also doubt that the four principles carry relevance outside the Western tradition, or prove useful to nonWestern patients and providers. Critics worry that imposing Western values on individuals from nonWestern cultures is an unacceptable form of ethnocentrism. In response to this concern, Jameton11 recommends that nurses combat ethnocentrism by paying careful attention to the cultural backgrounds of staff members and patients and learning more about their similarities and differences on important ethical issues. In this way, Western health professionals who support the four principles can invoke them in a culturally sensitive manner. Others suggest designing innovative strategies to foster more flexible and culturally attuned care. 15 For example, a nurse attempting to obtain informed consent to surgery from a traditional Navajo patient who shuns talking about negative risks can devise alternative means of achieving the goal of informed consent. These may include providing risk information by referring to a hypothetical third party, while avoiding direct reference to the patient. A third and final objection raised against principlism holds that nursing comprises a distinct ethical sphere identified not with an ethics of principles and rules but instead with an ethic of caring.23 Just as Nightingale held that nursing reflects women's special nature and work that is separate from the physician's, 19 these critics maintain that "nursing requires its own description, possesses its own phenomena, and retains its own method for clarification of its own concepts and their meanings, relationships, and context." 17 On some analyses, an ethic emphasizing caring in the context of personal relationships is a moral orientation that tends to dominate the ethical thinking of girls and women.9 According to this interpretation, the principle-based
32
JECKER
mcxlel that currently dominates health care ethics reflects a male bias, while overlooking a "feminine" ethic or caring. 22 In response it can be said that the professional stereotype that assigns caring activity to nurses and women, while regarding curing as primarily the province of physicians and men, oversimplifies the practice of both nursing and medicine.18 On a practical level, it is obvious that physicians care both for and about their
patients; likewise, critical care nurses participate centrally in the activity of curing patients. To the extent that principles of autonomy, beneficence, nonmaleficence, and justice can be shown to exclude caring, it could be argued that these principles are incomplete. But this charge does not suffice to show that the four principles should be abandoned, only that they may not reflect the whole of ethics in health care.
- -
SUMMARY
Consideration of the ethical principles of autonomy, beneficence, norunaleficence, and justice can help to equip critical care nurses to deal with ethical conflicts that arise in nursing practice. Properly understood, these principles do not function as inflexible absolutes, but instead serve as "moral compasses" that help the nurse to get his or her bearings in difficult or uncertain situations.6 Those who appeal to the four principles should recognize that other cultural traditions may regard other ethical values as central. Finally, to the extent that principlism neglects ethical concerns related to caring and personal relationships, this approach is incomplete. Nurses and others who invoke an ethic of caring can advance ethical understanding by contributing a careful analysis of this concept and its role in ethical decision making.
REFERENCES 1. American Association of Critical-Care Nurses: The
2.
3. 4.
5. 6.
Role of Critical Care Nurse as Patient Advocate. Aliso Viejo, CA, 1989 American Nurses' Association: Code for Nurses with Interpretive Statements, 1976. In Jameton A (ed): Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ. Prentice-Hall, 1984 American Nurses' Association: Code for Nurses with Interpretive Statements, 1985. Kansas City, MO, American Nurses' Association, 1985, p 6 Beauchamp T, Childress J: Principles of Biomedical Ethics, ed 4. New York, Oxford University Press, 1994 Benner P: From Novice to Expen. Menlo Park, CA, Addison-Wesley Publishing Company, 1984 Churchill LR, Siman J: Principles and the search for moral cenainty. Soc Sci Med 23:461-468,
1986 7. Clouser KD, Gen B: A critique of principlism. Journal of Medicine and Philosophy 15:219-236, 1990 8. Florence Nightingale Pledge for Nurses. In Jameton A Ced): Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ, Prentice-Hall, 1984, p 316
9. Gilligan C: In A Different Voice. Cambridge, MA, Harvard University Press, 1981 10. Jameton A: Nursing Practice: The Ethical issues. Englewood Cliffs, NJ, Prentice-Hall, 1984, p 93 11. Jameton A: Culture, morality, and ethics. Critical Care Nursing Clinics of Nonh America 2:443-451, 1990 12. Jecker NS: Caring for "socially undesirable patients." Camb Q Healthc Ethics 5:1996, pp 500-510 13. Jecker NS: Fidelity to patients and resource constraints. In Campbell C, Lustig A (eds): Duties to Others. Boston, Kluwer Academic Publishers, 1994, pp 293-308 14. Jecker NS: Integrating professional ethics with normative theory: Patient advocacy and social responsibility. Theor Med 11:125-139, 1990 15. Jecker NS, Carrese JA, Pearlman RA: Caring for patients in cross-cultural settings. Hastings Cent Rep 25:6-14, 1995 16. Jecker NS, Pearlman RA: An ethical framework for rationing health care. Journal of Medicine and Philosophy 17:79-96, 1992 17. Jecker NS, Reich Wf: Contemporary ethics of care. In Reich Wf (ed): Encyclopedia of Bioethics, ed 2. New York, Macmillan Publishing Company, 1995, pp 336-344
ETHICAL DECISION MAKING IN CRITICAL CARE NURSING
18. Jecker NS, Self DJ: Separating care and cure. Journal of Medicine and Philosophy 16:285-306, 1991 19. Reverby SM: Ordered to Care: The Dilemma of American Nursing, 1840-1945. New York, Cambridge University Press, 1989, pp 41-43 20. Rushton CH: Creating an ethical practice environment: A focus on advocacy. Critical Care Nursing Clinics of North America 7:387-397, 1995
33
21. Scneiderman LJ, Jecker NS, Jonsen AR: Medical futility: Its meaning and ethical implications. Ann Intern Med 112:949-954, 1991 22. Tong R: Feminine and Feminist Ethics. Belmont, CA, Wadsworth Publishing Company, 1993 23. Watson J: Nursing: Human Science and Human Care. New York, National League for Nursing, 1988 Address reprint requests to Nancy S. Jecker, PhD University of Washington School of Medicine Department of Medical History and Ethics Box 357120 Seattle, WA 98195-7120
os99-5885/97 $0.00 + .20
Ethical Decision Making in the
Critical Care Patient
Principles and Methods of Ethical Decision Making in Critical Care Nursing Nancy S. Jecker, PhD
Is it ethical to use morphine drips not only to alleviate suffering but also to speed up the process of dying? What should be done when families insist on excessive and burdensome treatments that members of the health care team believe are not in the patient's best interest? Are cost-limiting measures ever justified if more expensive treatments would offer a potentially greater benefit or lesser risk to the patient? Should nurses participate in "slow codes" if they think a patient should be allowed to die but no do-not-resuscitate order has been written by the attending physician? Is withdrawal of nutrition and hydration similar to withdrawal of other medical interventions, such as respirators and dialysis machines, or do food and fluids carry deeper social meanings related to human caring and nurturance? Do you have a decision-making process for dealing with such ethical dilemmas? Or do you find yourself often making ethical decisions in a haphazard way, pushed in one direction or another by the pressures of time,
From the Department of Medical Histoiy and Ethics, University of Washington School of Medicine, Seattle, Washington
place, and circumstance? One of the challenges critical care nurses face is to function as effective moral agents in situations such as those in which decisions must be made quickly; when one's freedom and authority are constrained; when patients are unable to communicate effectively; when medical specialists tend to focus on discrete factual outcomes, often neglecting the patient's overall well-being; and when the pervasiveness of technology can encourage impersonal, efficiency-oriented interactions. These unique circumstances of critical care nursing make it all the more imperative that nurses consider in advance the ethical values at stake in clinical decisions, and hone skills of ethical decision making.
Principles of Health Care Ethics One approach to practical, ethical decision making in nursing directs attention to general ethical principles and argues that these principles represent the "common morality" shared by members of society.4 According to this approach, nurses ought to weigh such common values critically in making health care deci-
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 9 /Number 1 I March 1997
29
30
JECKER
sions. Among the ethical principles most frequently cited are autonomy, beneficence, nonmaleficence, and justice. Autonomy calls for respecting competent patients' choices and actions, even when these conflict with nurses' or others' perceptions of patients' best interests. Specifically, the principle of autonomy relates to the nurse's duty to know and advocate for the competent patient's considered decisions. It requires nurses to engage patients in conversations about their values and beliefs, and to assist patients by sharing information, answering questions, offering recommendations, minimizing environmental stressors, and facilitating communication among patients and other members of the health care team. 20 Both the American Nurses' Association (ANA)2 and The American Association of Critical Care Nurses1 regard patient advocacy and respect for patients' choices as an integral part of nursing practice. According to the ANA Code for Nurses, 2 "Whenever possible, clients should be fully involved in the planning and implementation of their own health care. Each client has the moral right to determine what will be done with his/her person; receive information necessary for making informed judgments; to be told the possible effects of care; and decide to accept, refuse, or terminate treatment." The principle of beneficence, by contrast, emphasizes that "the nurse's primary commitment is to the health, welfare, and safety of the client."3 This principle focuses attention on the consequences of nursing actions, and underscores that one of the central goals of nursing is to help the patient. In the critical care setting, health care providers can readily lose sight of the overall benefit or burden of treatment and focus more narrowly on producing discrete physiologic effects on body parts of organ systems. 21 Nursing benefits the patient as a person only when health professionals distinguish between effects, which are physiologic changes to the patient's body, and benefits, which refer to effects that the person can appreciate as good.
Nonmaleficence relates to the nurse's duty to avoid harming the patient. As Jameton10 notes, "Taken literally this principle would be impossible to follow in practice, since only the simplest forms of treatment do no harm." Instead, the requirement to do no harm asks one to consider whether or not the pain and discomfort that medical interventions cause are, on balance, outweighed by benefits patients receive. The principle of nonmaleficence has a long history in nursing. The nineteenth-century Florence Nightingale Pledge includes the promise to "abstain from whatever is deleterious and mischievous . . . and devote myself to the welfare of those committed to my care."8 A final principle, the principle of justice, relates to the nurse's duty to treat similar patients similarly. In its most general form, justice requires avoiding discrimination against patients on the basis of morally arbitrary features, such as age, sex, perceived social worth, or cultural/ethnic background. Thus a nurse who shows a lack of regard for a patient because he or she is poor and homeless behaves unjustly by failing to give the patient the respect deserved.12 Justice also refers to the more specific problem of distributing limited resources. In the health care setting, distributive justice concerns the question, What health care resources are due or owed to persons in a context of resource scarcity?16 For example, it might be claimed that patients with similar health care needs are owed equal access to health care, that patients deserve whatever services they are able to pay for, or that public health care dollars are owed first to persons who make the greatest social contributions. Questions of distributive justice may pose ethical conflicts for nurses when rationing of scarce resources interferes with advocating for the best interests of individual patients. 13• 14
Critique of Principlism The above framework, comprised of the ethical principles of autonomy, beneficence, non-
ETHICAL DECISION MAKING IN CRITICAL CARE NURSING
maleficence, and justice, is intended to assist with ethical decision making by calling attention to the morally relevant values at stake. On some accounts, the four principles offer ethical backing for general clinical rules and practices. For example, the ethical rule requiring providers to obtain patients' informed consent to treatment may be justified by appealing to the ethical principle of respect for the patient. The practice of withholding or withdrawing futile and burdensome interventions from dying patients may be supported by appealing to the ethical principle of nonmaleficence. This approach to ethical decision making, which has been referred to (originally by its critics7) as "principlism," is invoked widely, appearing both in the literature of health care ethics and in the practice of clinical ethics consultation. It is not free of criticism, however. Within nursing, critics of principlism charge that nurses and patients are ill served by rule-governed behavior. Thus, Benner5 argues that although the novice nurse appeals to principles to resolve nursing dilemmas, expert nurses develop critical judgment and practical experience that enable them to apply case-based critical analysis. She explains that "the rule-governed behavior typical of the novice is extremely limited and inflexible. The heart of the difficulty lies in the fact that since novices have no experience of the situation they face, they must be given rules to guide their performance." 5 By contrast, expert nurses have an enormous range of prior case experiences that enable them to make the right decision in a given situation. For the expert nurse, says Benner, analytic principles have only limited relevance, applying only to novel situations in which the nurse lacks prior experience. In response to this criticism, it can be said that even if resorting to principles to make clinical decisions is unnecessary in situations of moral clarity, ethical principles remain useful in many other cases. As the questions raised at the outset of this article suggest, nurses frequently encounter situations in which they are uncertain
31
about what action to take, or in which members of the health care team disagree about the best course of action. In such instances, identifying the underlying values at stake leads to a more thoughtful resolution of the case. Critics of principlism also doubt that the four principles carry relevance outside the Western tradition, or prove useful to nonWestern patients and providers. Critics worry that imposing Western values on individuals from nonWestern cultures is an unacceptable form of ethnocentrism. In response to this concern, Jameton11 recommends that nurses combat ethnocentrism by paying careful attention to the cultural backgrounds of staff members and patients and learning more about their similarities and differences on important ethical issues. In this way, Western health professionals who support the four principles can invoke them in a culturally sensitive manner. Others suggest designing innovative strategies to foster more flexible and culturally attuned care. 15 For example, a nurse attempting to obtain informed consent to surgery from a traditional Navajo patient who shuns talking about negative risks can devise alternative means of achieving the goal of informed consent. These may include providing risk information by referring to a hypothetical third party, while avoiding direct reference to the patient. A third and final objection raised against principlism holds that nursing comprises a distinct ethical sphere identified not with an ethics of principles and rules but instead with an ethic of caring.23 Just as Nightingale held that nursing reflects women's special nature and work that is separate from the physician's, 19 these critics maintain that "nursing requires its own description, possesses its own phenomena, and retains its own method for clarification of its own concepts and their meanings, relationships, and context." 17 On some analyses, an ethic emphasizing caring in the context of personal relationships is a moral orientation that tends to dominate the ethical thinking of girls and women.9 According to this interpretation, the principle-based
32
JECKER
mcxlel that currently dominates health care ethics reflects a male bias, while overlooking a "feminine" ethic or caring. 22 In response it can be said that the professional stereotype that assigns caring activity to nurses and women, while regarding curing as primarily the province of physicians and men, oversimplifies the practice of both nursing and medicine.18 On a practical level, it is obvious that physicians care both for and about their
patients; likewise, critical care nurses participate centrally in the activity of curing patients. To the extent that principles of autonomy, beneficence, nonmaleficence, and justice can be shown to exclude caring, it could be argued that these principles are incomplete. But this charge does not suffice to show that the four principles should be abandoned, only that they may not reflect the whole of ethics in health care.
- -
SUMMARY
Consideration of the ethical principles of autonomy, beneficence, norunaleficence, and justice can help to equip critical care nurses to deal with ethical conflicts that arise in nursing practice. Properly understood, these principles do not function as inflexible absolutes, but instead serve as "moral compasses" that help the nurse to get his or her bearings in difficult or uncertain situations.6 Those who appeal to the four principles should recognize that other cultural traditions may regard other ethical values as central. Finally, to the extent that principlism neglects ethical concerns related to caring and personal relationships, this approach is incomplete. Nurses and others who invoke an ethic of caring can advance ethical understanding by contributing a careful analysis of this concept and its role in ethical decision making.
REFERENCES 1. American Association of Critical-Care Nurses: The
2.
3. 4.
5. 6.
Role of Critical Care Nurse as Patient Advocate. Aliso Viejo, CA, 1989 American Nurses' Association: Code for Nurses with Interpretive Statements, 1976. In Jameton A (ed): Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ. Prentice-Hall, 1984 American Nurses' Association: Code for Nurses with Interpretive Statements, 1985. Kansas City, MO, American Nurses' Association, 1985, p 6 Beauchamp T, Childress J: Principles of Biomedical Ethics, ed 4. New York, Oxford University Press, 1994 Benner P: From Novice to Expen. Menlo Park, CA, Addison-Wesley Publishing Company, 1984 Churchill LR, Siman J: Principles and the search for moral cenainty. Soc Sci Med 23:461-468,
1986 7. Clouser KD, Gen B: A critique of principlism. Journal of Medicine and Philosophy 15:219-236, 1990 8. Florence Nightingale Pledge for Nurses. In Jameton A Ced): Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ, Prentice-Hall, 1984, p 316
9. Gilligan C: In A Different Voice. Cambridge, MA, Harvard University Press, 1981 10. Jameton A: Nursing Practice: The Ethical issues. Englewood Cliffs, NJ, Prentice-Hall, 1984, p 93 11. Jameton A: Culture, morality, and ethics. Critical Care Nursing Clinics of Nonh America 2:443-451, 1990 12. Jecker NS: Caring for "socially undesirable patients." Camb Q Healthc Ethics 5:1996, pp 500-510 13. Jecker NS: Fidelity to patients and resource constraints. In Campbell C, Lustig A (eds): Duties to Others. Boston, Kluwer Academic Publishers, 1994, pp 293-308 14. Jecker NS: Integrating professional ethics with normative theory: Patient advocacy and social responsibility. Theor Med 11:125-139, 1990 15. Jecker NS, Carrese JA, Pearlman RA: Caring for patients in cross-cultural settings. Hastings Cent Rep 25:6-14, 1995 16. Jecker NS, Pearlman RA: An ethical framework for rationing health care. Journal of Medicine and Philosophy 17:79-96, 1992 17. Jecker NS, Reich Wf: Contemporary ethics of care. In Reich Wf (ed): Encyclopedia of Bioethics, ed 2. New York, Macmillan Publishing Company, 1995, pp 336-344
ETHICAL DECISION MAKING IN CRITICAL CARE NURSING
18. Jecker NS, Self DJ: Separating care and cure. Journal of Medicine and Philosophy 16:285-306, 1991 19. Reverby SM: Ordered to Care: The Dilemma of American Nursing, 1840-1945. New York, Cambridge University Press, 1989, pp 41-43 20. Rushton CH: Creating an ethical practice environment: A focus on advocacy. Critical Care Nursing Clinics of North America 7:387-397, 1995
33
21. Scneiderman LJ, Jecker NS, Jonsen AR: Medical futility: Its meaning and ethical implications. Ann Intern Med 112:949-954, 1991 22. Tong R: Feminine and Feminist Ethics. Belmont, CA, Wadsworth Publishing Company, 1993 23. Watson J: Nursing: Human Science and Human Care. New York, National League for Nursing, 1988 Address reprint requests to Nancy S. Jecker, PhD University of Washington School of Medicine Department of Medical History and Ethics Box 357120 Seattle, WA 98195-7120