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Nursing profession and the ethics of care.

An article appeared last Wednesday on the “Daily Mail” referred to a report of the Healt Service Ombudsman concerning to the treatment given to the elderly in British Hospitals. The report recounted several cases of abuse and neglect received by elderly. Among the examples, the report cites the cases of elderly who do not receive food or water for days or who are neglected in his room without receiving the minimum hygienic care over weeks.
The article’s author asserts that these behaviors show that the elderly have lost all the respect they have always had in society. He focuses in the work of nurses in Hospitals and says that their negligence is due to the lack of vocational sense of the nursing profession. Without doubt, it’s a fundamental reason, but in my opinion we should take account other important element not less important: the lack of an ethics of care in the practice of nursing profession.
Certainly, along history the elderly have been object of veneration and respect as they were holder of great wisdom and experience that they transmitted to the following generations. Our parents gave us our live and raised us to be who we are today. For that reason, the sons’ moral duty was to care of their parents in the best way possible. However, this mentality has deeply changed. The knowledge that elderly could transmit to us is useless for us because of the development of new technologies, the cultural change and the migrations from country to the city. Our world is not the world of our grandparents. On the one hand, traditional works are being lost, agricultural techniques changed and the ancient traditions were forgotten. The wisdom of the elderly is despised and is replaced by the technological knowledge of young researchers, who develop the most revolutionary inventions. On the other hand, the model of country “broad family” in which woman was at home caring of the elderly and ills became in small families living in small flats in the city and in which husband and wife work. So, there is anybody to care of the grandparents at home. However, the internment of the grandparents in a Hospital doesn’t seem a good option at all, as the article shows.
But why does this lack of respect toward the elderly in the Hospitals if the duty of nurses is to provide a good care to all patients? In my opinion one of the keys to understand this elder abuse is a lack of an ethics of care in the nursing profession. The concept of “ethics of care” was employed by several authors; among them we should stress to Carol Gilligan. She opposed the “ethics of justice” (which she related to Kohlberg) to the “ethics of care” that she supported. These are two different ways to understand the relations among persons. The ethics of justice is grounded in abstract moral principles, the defence of formal rights and social atomism on minimal rules of coexistence. In contrast, the ethics of care focuses the attention in the particularities, the mutual relation with the other, the sympathy and the responsibility. It values not only the formal rules, but other sentimental elements which give sense to interpersonal relations. In this sense, while the ethics of justice has a cognitive sense, the ethics of care gives a main role to the emotions and virtues. Only the promotion of emotions and virtues can provide a humane treatment to ill and elderly. In contrast, the rational calculation of the optimization of resources will lead to commit the abuses mentioned in the article. Therefore it is necessary to promote an ethics of care in the exercise of the profession of nursing.
And which are the elements that articulate the ethics of care? This ethics requires not only a vocational attitude, which is essential, but also the development of other attitudes and virtues necessary to convert a minimum (the due treatment to elderly) into a maximum: the correct practice and professional excellence. Some virtues that should guide the profession of nursing to achieve professional excellence would be the following ones:
– Compassion for the person who depends on the nurse. Compassion is the ability to locate where the person suffering.
– Competition: it’s the reasoning ability, skills, experience and motivation to respond to the issues raised in the exercise of the profession. The good nurse tries to be excellent in the course of their work. Competition should therefore complement the compassion because compassion without competition would only be a good intention while competence without compassion can be inhumane.
– Trust: This is a relationship that should be essential between the elderly and the nurse, as it presupposes both truthfulness and mutual respect. The elderly receive adequate treatment only if he or she can feel safe and supported by medical staff and nurses. So honesty is a core value too. Hence we can understand the relevance of this virtue in an ethics of care.
– Responsibility: The nurse must feel responsible for the welfare of the person who has been entrusted to their care.
– Attention: The core of the practice of care should always be the patient. Hence the main interest of nurses should be the search for internal goods of their profession and not external goods, as could be the profit. Otherwise, the health profession would be flawed.

These virtues embody the ethics of care that is necessary to promote the education of healthcare not only to prevent the abuses that might occur in nursing profession, but to promote a professional excellence. Professionals should always aspire to excellence. Only in this way elderly can regain the care and respect they deserve in our society.

Gilligan, Carol. In a different voice: psychological theory and women’s development. Harvard University press, Cambridge, Ma., 1982.

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3 Comment on this post

  1. Isn't there an ethics of promise-keeping, which resolves into doing the job you signed up for to the best of your ability? Forget the ethics of care or compassion. Old folks smell funny and are often odd-looking. They don't always cooperate. But the nurse who takes the job has to know this, or at least learn this on the job. If (s)he can't do it, (s)(he should leave.

    Nursing job is the kind of job in which surprising problems arise and need to be resolved by the nurse, using his or her best efforts — to do what nurses are trained to do. A contract of the sort a nurse (or a physician or an electrician or a plumber or a legal practitioner or a judge) enters into is more than a promise to do a routine job well. That's because there are often non-routing jobs to do. You can call this a matter of professional ethics, but I prefer to eschew such self-aggrandizing terms and talk simply about the ethics of promise-keeping.

  2. This commentary has some of the most severe gaps in logic I have ever seen. How does one truly horrible report (which is of course quite tragic) damn an entire profession that is literally thousands of years old? On what are you basing this opinion of yours? Is it a hunch? Do you just want to blame someone? It is rather easy for a man to blame a profession that is predominantly occupied by women, isn't it?

    And … virtues? Should nurses go back to white dresses, maybe some wings and a courtesy? Perhaps rather than determining who can be a nurse or how a person should change in order to become a nurse, you could suggest that an already well-established code of ethics is not being followed. The first element of the International Council of Nurses (ICN) Code of Ethics indicates that an environment that respects the patient's values, culture, etc.

    What is even more relevant is that the NHS executives' salaries have increased by 50% while staff are losing their jobs. In defense of those who do not participate in outright neglect, nurses often face more patients with many needs than can in any reasonable way be handled. Your commentary, sir, deserves nothing less than to be wholly rewritten or removed from public discourse.

  3. This commentary was difficult to digest for its lack of a rational argument and complete lack of supporting evidence. As a nurse, bioethicist, and researcher, I found this commentary to be unfounded in its assumptions and, quite frankly, insulting.

    It is ridiculous to cite the "lack of vocational sense" in nursing as a "fundamental reason" for elder abuse in British Hospitals. The author's use of the word "vocational" invokes the old conception of individuals pursuing nursing; nurses were perceived as having a "calling to serve," that focuses on developing skills instead of academic knowledge. This is an ancient concept in both nursing and the modern health care system.

    We have seen an advancement in technologies, pharmaceuticals, and other treatments that have revolutionized the health care system and society itself. These advancements have allowed us to prolong life beyond previously established limits. Better medications and therapies have created a growing aging population. Chronic disease has become the leading cause of death, rather than acute illnesses. All of these factors combined has put a strain on society in terms of how to approach modernized health care on a philosophical level, what to do with the continuous growing number of elderly, and develop a health care system that can support growing costs. But perhaps we should ignore all of these factors and reduce the elderly abuse in hospitals down to a "lack of ethics of care" in nursing?

    The author states we should use an "ethics of caring" in nursing instead of "ethics of justice," and cites Carol Gilligan as his main source. While there is a sense of paternalism in the principlism system in bioethics, Gilligan's "ethics of caring" has been criticized for its reinforcement of traditional stereotypical "feminine values;" the author fails to address this criticism. Perhaps instead of jumping from an arguably paternalistic ethical system to a feminist moral theory, one can find a middle-ground bioethical framework that addresses the real contextual issues at hand.

    Elder abuse occurring in British Hospitals, as well as in other health care facilities around the world, is both tragic and unacceptable. As a human-being, participating member in society, and nurse, I find these reports of abuse to be sickening and unfortunate for many reasons. The elderly are truly gems of our society; as the author states, they have a great deal of wisdom from long life experience, and deserve nothing less than our continuous respect. Unfortunately, the treatment elders receive in our health care system does not reflect respect.

    While I agree with the author that something needs to be done to improve the caring elders receive in hospitals, and an explicit conversation about ethics in nursing needs to begin, I find the subsequent statements made in his commentary to be unsubstantiated and revolting. What could have been an enlightening piece on nursing ethics within a health care system that permits travesties, such as elder abuse, has turned into a roast of the nursing profession.

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