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The effect of quality of life and sanctity of life on clinical decision making
AORN JOURNAL
MAY 1985, VOL 41, N O 5
Ethics The effect of quality of life and sanctity of life on clinical decision making
alues influence decision making in several ways. The way people see or define a problem is based, at least partially, on their values. It is only when I value equality that I see the injustice of sexist comments. Only when I value quality patient care do I define discharging patients before they are ready to care for themselves as a problem. Only when I value life do I begin to raise questions about death. The decisions one makes between alternatives are also influenced by values. If I only have time to either pass medications or talk with Mr Jones’ family, my choice will reflect what I value most. If I value psychosocial aspects of patient care more than I value the physical aspects, I will choose to talk with Mr Jones’ family before passing the
V
medications. If, however, I know that decision would lead to disciplinary action, I may choose to forego talking with the family even though I value that interaction. This decision would show I value personal comfort more than interaction with a patient’s family. Though values are central to decision making, they can be used only when identified and prioritized. Within different cultures, certain values have higher priority than others. For example, a value held in high esteem by Americans is individual dignity. Health care as a social institution is founded on the value of the worth of the person and the right to human wholeness and integrity.
Quality vs Sanctity
I
G. Taylor, RN,PhD, is an associate professor at the University of Missouri School of Nursing, Columbia She earned a doctorate in higher education administration and a master’s of science in nursing at The Catholic University of America, Washington, DC. She earned her BSN at Alvemo College, Milwaukee. Susan
924
n current discussions, the issues of sanctity of life and quality of life have become slogans for two opposing views on the meaning of life. Sanctity of life is used to represent a belief in the intrinsic holiness and value of human existence, generally because of its relationship to God; hence, all human life is of equal value. Quality of life represents an attempt to put a value on some feature or collection of features.’ What constitutes quality of life is a subjective decision and assumes that all human lives are not of equal value. When this determination is made, decisions about rights, such as the right to life or to certain kinds of health care, follow. Views on quality of life and sanctity of life are usually discussed in regard to decisions about life and death, such as do not resuscitate orders
AORN JOURNAL
MAY 1985, VOL 41, N O 5
Of importance to the provider is the consistent and just application of a set of principles in decision making. or abortion. Health care providers originally labeled the dilemma of prolonging life as one of quantity versus quality. Those arguing for quantity of life believed that all life was of equal value and had meaning. This has led to restatement of the position as sanctity of life because the proponents of this value were concerned not with quantity of life, but with the intrinsic worth of human existence. Quality of life proponents believe that no life at all is better than a life with certain deficits. Making decisions based on quality of life is problematic because of the absence of criteria for determining quality. Jonsen and colleagues said that the determination of quality usually refers to a “subjective evaluation by an onlooker about another’s life, when the other is unable to make such an evaluation or express it because of mental incapacity.”2There is little agreement about what constitutes quality, though a number of attempts have been made. Using quality of life as a criteria in health care decisions needs to be looked at carefully. The sorts of judgments that healthy, intelligent, socially accomplished, and technically skilled persons make about the ill, incompetent, or uneducated and unskilled are very likely to be biased. Differences of social and economic class can lead to widely different views of what constitutes a tolerable quality of life. The acceptance of quality of life as a criterion for treatment decisions can lead to undesirable social consequences. Judgments of good and bad quality may begin with quite generally accepted notions and be slowly enlarged and generalized. All sorts of ‘unameptables’ can be swept into the category of persons living lives of poor quality: hippies,gypsies, the uneducated and illiterate,persons of low intelligenceor with physical handicaps. . . . Persons who fall into these vague categories may no longer be seen as deserving of help? 926
Appbing the Principles
P
roponents of the sanctity of life argument hold that personhood exists from the beginning of life, ie, conception or another defined point, to the time that brain death is established. Life itself is a paramount right that must be protected. This position becomes a concern when two people’s rights conflict, such as when two people require life-saving treatment simultaneously and only one health care provider is available. With the sanctity of life value, where life must be preserved at all costs in all situations, resources become a problem. Because resources are finite, some decisions are needed for fair distribution; it may not be possible to preserve all life. Further, some treatment procedures, it is argued, are affronts to the sanctity of the person. When such treatment can be withheld while maintaining sanctity of life needs to be defined. Of importance to the health care provider is the consistent and just application of a set of principles or values in decision making. If a nurse values sanctity of life, that value should apply at all points on the life continuum. Value judgments about quality should not be arbitrary; consistency will result in explainable and coherent decisions. The sanctity of life view needs consistent sets of criteria to determine the presence of life or personhood, while the quality of life view needs consistent sets of criteria for determining the quality of life at all points of life. If my primary belief is in the sanctity of life theory, I will probably argue against abortion, active euthanasia, or unnecessary surgery and argue for treatment of defective newborns, equal access to health care for all, or prolongation of life at all costs. If my primary belief is in the quality of life theory, I will probably argue against treatment for certain classes of defective newborns or prolongation of life in certain circumstances, such as terminal cancer. Depending on the criteria
AORN JOURNAL
I accept for quality, I may argue for abortion, active euthanasia, and withholding treatment from certain classes of individuals, such as severely brain damaged children. Most health care providers hold views about the nature of man and his relationship with others that incorporate beliefs about the intrinsic value of the human and the subjective value of certain features of existence. We need to analyze these beliefs, how they interact with the beliefs of those around us, and how they guide our patient care decisions. There are many excellent resources for beginning this critical appraisal of our beliefs, including the series prepared by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral
MAY 1985, VOL 41, NO 5
Research. Of particular interest are the reports on defining death and deciding to forego lifesustaining treatment, available from Superintendent of Documents, US Government Printing Office, Washington, DC. It is our responsibility to make ethical decisions for ourselves and our patients. This imposes the obligation to know our basic values and how to use them in decision making. SUSAN G. TAYLOR, RN Notes 1. A R Jonsen, M Seigler, W J Winslade, Clinical Ethics (New York City: MacMillan Co, 1982) 110. 2. Zbid 113. 3. Zbid, 124.
When Laying Off Staff Cannot be Avoided When the chief of nursing must cut the nursing staff, it is a time of stress for all invoIved. An article in the January Journal of Nursing Administration describes the steps to take. In the section focusing on achieving a smooth layoff, the authors outline 10 important steps. First, include managers from the head nurse on up about the changes and those on their staff who will be affected by either a layoff or a status change. While the authors state that it is necessary to explain the confidential nature of the discussions, they believe, “to exclude your nursing management team, especially if they have been involved in participative management, could be an act of political suicide.” Those new managers may be frustrated by the layoffs and will need support from nursing administrators. Once the decision is made, arrange to have all the layoffs including the necessary paperwork completed in one week. During this period, the rumor mill will be working overtime, but the authors caution against fighting the rumors. They say that the rumor mill is one way for the staff to prepare for the upcoming changes. Only in cases where serious misinformation is flowing through the mill should the directors try to get involved. In those cases, correct information can be com928
municated formally or informally. While physicians and other managers need to be aware of the plans to lay off nursing staff, do not expect that they will keep the information confidential. For this reason, all nursing managers should know about the plan before talking to others. For a smooth layoff, it is also necessary to coordinate efforts with the personnel or payroll department. Having paychecks and clearances readily available will minimize the trauma of the process. All departments should receive written notification of the layoff schedule. Plan to talk to the employees who will be laid off individually or in small groups of no more than four employees. This is important for those being laid off and the remaining staff as it reflects respect for the employees and concern about the situation. Once the process is complete, arrange to have first-line supervisors meet with their staff to answer questions and reassure them that business will now proceed as usual.
MAY 1985, VOL 41, N O 5
Ethics The effect of quality of life and sanctity of life on clinical decision making
alues influence decision making in several ways. The way people see or define a problem is based, at least partially, on their values. It is only when I value equality that I see the injustice of sexist comments. Only when I value quality patient care do I define discharging patients before they are ready to care for themselves as a problem. Only when I value life do I begin to raise questions about death. The decisions one makes between alternatives are also influenced by values. If I only have time to either pass medications or talk with Mr Jones’ family, my choice will reflect what I value most. If I value psychosocial aspects of patient care more than I value the physical aspects, I will choose to talk with Mr Jones’ family before passing the
V
medications. If, however, I know that decision would lead to disciplinary action, I may choose to forego talking with the family even though I value that interaction. This decision would show I value personal comfort more than interaction with a patient’s family. Though values are central to decision making, they can be used only when identified and prioritized. Within different cultures, certain values have higher priority than others. For example, a value held in high esteem by Americans is individual dignity. Health care as a social institution is founded on the value of the worth of the person and the right to human wholeness and integrity.
Quality vs Sanctity
I
G. Taylor, RN,PhD, is an associate professor at the University of Missouri School of Nursing, Columbia She earned a doctorate in higher education administration and a master’s of science in nursing at The Catholic University of America, Washington, DC. She earned her BSN at Alvemo College, Milwaukee. Susan
924
n current discussions, the issues of sanctity of life and quality of life have become slogans for two opposing views on the meaning of life. Sanctity of life is used to represent a belief in the intrinsic holiness and value of human existence, generally because of its relationship to God; hence, all human life is of equal value. Quality of life represents an attempt to put a value on some feature or collection of features.’ What constitutes quality of life is a subjective decision and assumes that all human lives are not of equal value. When this determination is made, decisions about rights, such as the right to life or to certain kinds of health care, follow. Views on quality of life and sanctity of life are usually discussed in regard to decisions about life and death, such as do not resuscitate orders
AORN JOURNAL
MAY 1985, VOL 41, N O 5
Of importance to the provider is the consistent and just application of a set of principles in decision making. or abortion. Health care providers originally labeled the dilemma of prolonging life as one of quantity versus quality. Those arguing for quantity of life believed that all life was of equal value and had meaning. This has led to restatement of the position as sanctity of life because the proponents of this value were concerned not with quantity of life, but with the intrinsic worth of human existence. Quality of life proponents believe that no life at all is better than a life with certain deficits. Making decisions based on quality of life is problematic because of the absence of criteria for determining quality. Jonsen and colleagues said that the determination of quality usually refers to a “subjective evaluation by an onlooker about another’s life, when the other is unable to make such an evaluation or express it because of mental incapacity.”2There is little agreement about what constitutes quality, though a number of attempts have been made. Using quality of life as a criteria in health care decisions needs to be looked at carefully. The sorts of judgments that healthy, intelligent, socially accomplished, and technically skilled persons make about the ill, incompetent, or uneducated and unskilled are very likely to be biased. Differences of social and economic class can lead to widely different views of what constitutes a tolerable quality of life. The acceptance of quality of life as a criterion for treatment decisions can lead to undesirable social consequences. Judgments of good and bad quality may begin with quite generally accepted notions and be slowly enlarged and generalized. All sorts of ‘unameptables’ can be swept into the category of persons living lives of poor quality: hippies,gypsies, the uneducated and illiterate,persons of low intelligenceor with physical handicaps. . . . Persons who fall into these vague categories may no longer be seen as deserving of help? 926
Appbing the Principles
P
roponents of the sanctity of life argument hold that personhood exists from the beginning of life, ie, conception or another defined point, to the time that brain death is established. Life itself is a paramount right that must be protected. This position becomes a concern when two people’s rights conflict, such as when two people require life-saving treatment simultaneously and only one health care provider is available. With the sanctity of life value, where life must be preserved at all costs in all situations, resources become a problem. Because resources are finite, some decisions are needed for fair distribution; it may not be possible to preserve all life. Further, some treatment procedures, it is argued, are affronts to the sanctity of the person. When such treatment can be withheld while maintaining sanctity of life needs to be defined. Of importance to the health care provider is the consistent and just application of a set of principles or values in decision making. If a nurse values sanctity of life, that value should apply at all points on the life continuum. Value judgments about quality should not be arbitrary; consistency will result in explainable and coherent decisions. The sanctity of life view needs consistent sets of criteria to determine the presence of life or personhood, while the quality of life view needs consistent sets of criteria for determining the quality of life at all points of life. If my primary belief is in the sanctity of life theory, I will probably argue against abortion, active euthanasia, or unnecessary surgery and argue for treatment of defective newborns, equal access to health care for all, or prolongation of life at all costs. If my primary belief is in the quality of life theory, I will probably argue against treatment for certain classes of defective newborns or prolongation of life in certain circumstances, such as terminal cancer. Depending on the criteria
AORN JOURNAL
I accept for quality, I may argue for abortion, active euthanasia, and withholding treatment from certain classes of individuals, such as severely brain damaged children. Most health care providers hold views about the nature of man and his relationship with others that incorporate beliefs about the intrinsic value of the human and the subjective value of certain features of existence. We need to analyze these beliefs, how they interact with the beliefs of those around us, and how they guide our patient care decisions. There are many excellent resources for beginning this critical appraisal of our beliefs, including the series prepared by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral
MAY 1985, VOL 41, NO 5
Research. Of particular interest are the reports on defining death and deciding to forego lifesustaining treatment, available from Superintendent of Documents, US Government Printing Office, Washington, DC. It is our responsibility to make ethical decisions for ourselves and our patients. This imposes the obligation to know our basic values and how to use them in decision making. SUSAN G. TAYLOR, RN Notes 1. A R Jonsen, M Seigler, W J Winslade, Clinical Ethics (New York City: MacMillan Co, 1982) 110. 2. Zbid 113. 3. Zbid, 124.
When Laying Off Staff Cannot be Avoided When the chief of nursing must cut the nursing staff, it is a time of stress for all invoIved. An article in the January Journal of Nursing Administration describes the steps to take. In the section focusing on achieving a smooth layoff, the authors outline 10 important steps. First, include managers from the head nurse on up about the changes and those on their staff who will be affected by either a layoff or a status change. While the authors state that it is necessary to explain the confidential nature of the discussions, they believe, “to exclude your nursing management team, especially if they have been involved in participative management, could be an act of political suicide.” Those new managers may be frustrated by the layoffs and will need support from nursing administrators. Once the decision is made, arrange to have all the layoffs including the necessary paperwork completed in one week. During this period, the rumor mill will be working overtime, but the authors caution against fighting the rumors. They say that the rumor mill is one way for the staff to prepare for the upcoming changes. Only in cases where serious misinformation is flowing through the mill should the directors try to get involved. In those cases, correct information can be com928
municated formally or informally. While physicians and other managers need to be aware of the plans to lay off nursing staff, do not expect that they will keep the information confidential. For this reason, all nursing managers should know about the plan before talking to others. For a smooth layoff, it is also necessary to coordinate efforts with the personnel or payroll department. Having paychecks and clearances readily available will minimize the trauma of the process. All departments should receive written notification of the layoff schedule. Plan to talk to the employees who will be laid off individually or in small groups of no more than four employees. This is important for those being laid off and the remaining staff as it reflects respect for the employees and concern about the situation. Once the process is complete, arrange to have first-line supervisors meet with their staff to answer questions and reassure them that business will now proceed as usual.