Nursing's respect for patients and their convictions
Gonzalo Herranz. department of Bioethics, University of Navarra
discussion paper at the I International Symposium on Ethics in Nursing
University School of Nursing, University of Navarra, Spain.
Pamplona, Spain, September 6-8, 1989.
I. The deontological respect of the nurse
II. The layers of respect in nursing
First layer: respect as a correct attention
Second layer: respect for the patient's body
Third layer: respect for convictions
III. The internship of the respect for convictions
I would like to thank the organizers of the Symposium for their invitation to participate in it: apart from being an honor, it provides me with the opportunity to deal with a topic, respect for the patient and his convictions, which is very dear to me. I have a very strong opinion about the role that respect plays in the moral life of health professionals.1and I am very interested in the relationship between medical ethics and religious belief.2.
The discussion paper, as pointed out by its degree scroll, confronts us with three problems: The first is to determine what deontological respect consists of for a Nurse. The second raises the question of how the nurse should respond to the different levels of respect demanded by the patient, from the lowest level of external and material things to the most interior and spiritual of convictions. Finally, we must address the question of how to respect the patient's personal convictions.
Let's start by examining the first one.
I. The deontological respect of the nurse
For the Nurse, respect is, above all, a deontological obligation, a duty imposed by the rules and traditions of the profession. The Code for Nurses of the International Nursing committee solemnly declares, at the very beginning, that respect - in its triple aspect: respect for life, dignity and the rights of man - is inherent to the profession of Nursing and is not limited by considerations of nationality, race, creed, color, age, sex, politics or social rank. And a little further on, in dealing with the relationship between the Nurse and individuals, she adds that, in administering care, the Nurse respects the beliefs, values and customs of each individual. These ideas are very rich in content and it is logical that they have found an echo in the Codes of Conduct of many national Nursing Associations.
A curious thing happens, however: the same Codes that oblige us to respect do not tell us anything, or tell us very little, about the essence and manifestations of deontological respect. When they do, they tend to identify deontological respect with Kantian ethics' respect for the autonomy and dignity of the human person. This is due, in my opinion, to the influence exerted by the Code for Nurses of the American Nursing association , in its 1976 version with its Interpretative Comments, which has been a highly effective instrument in the transmutation of the model Nurse-patient relationship of the professional tradition inherited from Florence Nightingale, into the Nurse-client relationship of today's consumerist culture. We cannot forget that the Kantian idea of respect lends itself very well to give ethical-legal support to the autonomism of North American individualistic Bioethics. But we are beginning to see clearly now that, on the whole, the change has not result been a big deal: there are other interpretations of respect as a fundamental ethical attitude that are more realistic, more constructive and that retain many of the permanent values of the profession.
I prefer to consider deontological respect as a fundamental ethical attitude that permeates the moral life of the nurse. It becomes like the nervous system of her moral life, through which the Nurse perceives, integrates and responds to the ethical values of which she is the holder, by the simple fact that she is a human being, each one of her patients. It is obvious that the abundance and quality of the Nurse's ethical responses depend on the Degree in which she has sought to develop her sensitivity to grasp the moral values that are present in her encounters with each of her patients and on the intensity and extent to which she has exercised her capacity for judgment to weigh those values and to take them into account when making her decisions. The importance of respect is revealed most dramatically when it is neglected and lost. Its lack makes us rude or blind, sometimes brutal, to the ethical problems of the profession.
Deontological respect should make us experts in perceiving the elements of the dignity of each person, even under the very different and sometimes impoverished appearances in which he presents himself to us when he suffers from illness or handicap. If we sincerely lived deontological respect, we would be challenged by the human dignity of the mentally handicapped as well as by that of the physically handicapped, by that of the fussy old man as well as that of the terminally ill, by that of the chronic patient no less than that of the urgent case. They are all, without distinction, human beings who, regardless of their legal rights, are supremely and equally valuable and worthy. Nothing that they may lack in size, appearance, intellectual wealth or physical plenitude, none of these, including all their deficiencies and handicaps, can diminish their human dignity in our eyes, because to make up for what they lack there is our dedication and our respect.
Therefore, deontological respect in nursing has this specific trait: it illuminates our relationship with human beings who are more or less affected, to a greater or lesser extent, by disease Degree. We health professionals exist for them. To us come, or are brought, the weak, the handicapped, those who fear they are losing physical vigor, mental Schools or life itself. Our relationship with them is asymmetrical, with skill and science on our side; fear and weakness on theirs. Our official document is to be in immediate contact with their pain to alleviate it, with their handicap to rehabilitate it, with the risks that threaten their weakened health to prevent them. Although experience teaches us that health for all is an unattainable goal and that it is utopian to aspire to the paradisiacal state of complete physical, psychological and social well-being, that same experience reveals to us that real health is, in its imperfection, something much more amazing, because it is something much more human: health consists of living with limitations. It is to these threatened and limited lives that our work is directed.
Let's move on to our second point.
II. The layers of respect in nursing
I will now attempt to provide a description, albeit incomplete, of the manifestations of deontological respect for the nurse. For this purpose, I will arbitrarily distribute the material into three levels or strata.
First layer: respect as a correct attention
At its most elementary level, respect is respect, consideration. In this sense, professional respect obliges the nurse to have a polite and correct relationship with patients and accompanying persons, with physicians and with all those who collaborate with her in the field of health care. This respect, made of courtesy and good manners, is not simply the externalization of certain cultural conventions: it is, over and above the ups and downs of mood, an excellent way of expressing one's appreciation for others. The internship of respect is one of the most valuable products of the long process educational to which we devote so many years of our lives, a process that, at its core, tries to create in us the conviction that others, particularly the weaker ones, are important. Since the Nurse usually deals with human beings who are more or less weakened, physically or morally, by illness, one can understand the importance that this polite respect must have in her work.
Polite respect has, in the work of the Nurse, a thousand different manifestations. Each of them may seem insignificant, microscopic, but, in reality, they are all loaded with a strong symbolism that cannot be underestimated. The manifestations of polite respect are a tangible marker, on a collective level, of the quality of care administered by an institution and define, indirectly but reliably, the ethical atmosphere that permeates it.
Respect for the good Education could be called respect for the little things. And we all know that it is the little things, the details, that contribute most decisively to making life pleasant or unbearable for the sick person.
Caring for the physical environment of the patient is a manifestation of respect. For this reason, very material and apparently not very dignified tasks, such as cleaning the rooms and corridors, changing bed linen, combating environmental pollution anddirt3,4, eliminating unpleasant odors and noises, have great importance and status. It is important that the beds are comfortable for the patients, not only functional for doctors and nurses; that the food is appetizing and served at an acceptable temperature; that the sanitary facilities (washbasin, toilet, shower) are kept clean, that towels are renewed with due regularity. All these things are not just matters of hygiene or public relations: they are, above all, manifestations of respect.
In the rules of the ordinary good Education the Nurse can find inspiration for many actions and omissions in the attention with people. When a Nurse understands in depth what respect is, even at this most rudimentary level, and tries to live it, nothing is indifferent to her. And so, the way she presents herself (the neatness of the uniform, the composure, the care staff) is not only a regulatory or contractual obligation, nor only sample of self-esteem: it is the appropriate response to the dignity of her patients.5. Promptly answering the patient's calls and doing so with a willingness to listen and respond to questions or requests, often irrelevant or capricious, contributes to improving the quality of care, but, above all, it is a manifestation of respect for those who are more or less frightened by the disease. The respectful manners with which the nurse addresses her patient (calling him, as the case may be, by his name or his surname, refraining from any subject of familiarity or avoiding expressions that tend to infantilize adults, dealing delicately and not in a shouting voice with more or less intimate matters) do not come from spontaneity or temperament. They are the result of balancing, with intelligence and sensitivity, two duties imposed by polite respect: that of keeping the forms and social conventions and that of treating with kindness, cordiality and courtesy.6.
The kind correction that informs the Nurse's work also has a modulating effect on the patient's behavior, both in the hospital and in the outpatient enquiry . In recent years, much has been said and written about the rights of the sick, but little about their duties. This can be explained by the predominantly political nature of the enactment of patient charters by the respective Ministries of Health in many places. Patients' responsibilities should be proclaimed with energy similar to that which is put into declaring their rights. Judging by the verbal aggressiveness that certain patients use in their relationship with the health or administrative staff , by the issue of petty theft or deliberate physical harm, it seems that the issue of users whose behavior falls below what is desirable for friendly coexistence is constantly growing. The care of the rules of the Education by doctors and nurses is, in my opinion, an excellent procedure to induce in patients and their relatives a respectful behavior for things and people in the hospital, the most effective way to tell them that they too should behave well. The correctness and rationality that the Nurse puts into her relationship with the patient usually elicits from the patient a proportionate response of correctness and rationality.
Second layer: respect for the patient's body
The care or neglect of the material details that affect the patient's body takes on a particular significance, because, in general, the sick person, unlike the healthy one, has a very vivid and acute perception of his body. The body of the sick person emits more and more disturbed signals, it makes its presence felt much more intensely than the body of the healthy person. For this reason, and not only because of its altered pathophysiology, we are obliged to treat it with greater respect.
There is obviously a widespread ignorance among doctors and nurses about the significance staff and human significance of the body. They know a lot about Anatomy and physiology, and that is fundamental, but they are largely unaware of the anthropology of the body. This is the only way to explain why certain gestures expressing respect for the body are so often neglected in hospitals today. These omissions or negligence are of very varied types, of which I will only refer to two.
The first is the specific neglect of the body, which is no longer, or only slightly, monitored by the consciousness that inhabits it, as happens to certain senile patients with a dull sensorium, to those in coma or under general anesthesia. The absence of sensitivity in these patients, their incapacity to protest, the cancellation of a large part of their defense or protection reflexes, demand from us a particular pampering: we must be for these patients their five senses and their brain, in order to feel and react for them. When I worked as a pathologist, I was very sad to observe in autopsies a particular type of iatrogenic pathology subject : that formed by injuries (decubitus ulcers, aspiration of vomit, laryngeal erosions due to oversized endotracheal cannulas, diffuse hemorrhages around venous puncture points, excoriations due to violent tearing of adhesive tape) that in life caused annoying discomfort for the patient and that were due to the negligence or inattention of doctors or nurses. Many of them could have been avoided with a little zeal or respect for human tissues. We cannot forget that we have an almost religious obligation to respect the physical, material dignity of the human body, temple of the soul and material substratum of the person. I believe that this is a field in which the delicacy and the professional skill of the Nurse can be expressed in an infinite variety of nuances and services. It is necessary, for this, that the Nurse is persuaded that in each patient that she takes care of, in each sick body that she takes care of, a human life is entrusted to her, not in abstract, but in an unrepeatable corporeality.
Secondly, we must protect the patient's body not only from physical harm: we must spare him the moral suffering derived from the neglect of modesty. It cannot be said that the way modesty is protected today in some hospitals is excellent. It is not tolerable for room doors to remain open while patients are being examined or treated and their nudity is exposed to the gaze of strangers. Many physicians, when performing the physical examination of the patient, seem to ignore the patient's feelings: they tolerate, for example, that the examination is interrupted to attend to non-urgent telephone calls or grant themselves the pleasure of an irrelevant conversation with a colleague, while their patient, in the gynecological position, waits. Obviously, for the physician such status is devoid of malevolent intent: he neither wishes to humiliate nor to cause suffering. But his behavior is disrespectful and reveals that his sensitivity is so calloused that he is no longer able to perceive the feelings of others. The nurses will have to play their role as the patient's advocates and will strive to tenaciously enforce the rules that have crystallized medical respect for the naked body.7.
Third layer: respect for convictions
In modern free societies, the protection of the philosophical and religious convictions of citizens has received particular attention, both in the constitutional texts of many nations and in their international agreements and in universal declarations of human rights. The Church has expounded its doctrine on this point in the Declaration "Dignitatis humanae" of the Second Vatican Council.
Nursing, as a profession, recognizes that the personal convictions of the patient must be, because of their nobility and dignity, the object of special respect and, logically, the Codes of Professional Conduct for Nurses proclaim the duty to respect the convictions of the patient. Thus, the Code for Nurses of the International Nurses committee states the duty, the fulfillment of which I take for granted, that "The Nurse, in providing care, respects the beliefs, values and customs of each individual".
How can the Nurse manifest respect for these convictions while administering care? In different ways.
Sometimes, he will respect them if, when they are irrelevant, as happens in his encounters with a large issue of patients, he ignores them, puts them aside and does not unduly invade the privacy staff of the patient. Respect is manifested here by respectful abstention, which is not negligence or disinterest, but a delicate way of not tampering with the privacy of others.
But, on many other occasions, the nurse will not be able to respect these convictions if, with due circumspection, she does not make an effort to learn about them. A complex process is then set in motion, which begins with a respectful inquiry into the patient's beliefs, continues with the nurse's own conscientious examination of how she should respond to her patient's convictions, and is perfected when the nurse discusses any points of conflict with her patient in an attempt to find solutions, to apply them if there are any, or to refrain from acting if she does not find them.
III. The internship of the respect for convictions
There are, therefore, three moments or phases in the internship of respect for convictions: a cognitive moment, a phase of negotiation and a time of decision.
The cognitive moment. The Nurse who inspires her conduct in respect is an awakened person, with an eye for details, so that she discovers in the course of her work many traits of her patient's personality. The patient states, sometimes openly, sometimes in indirect language, what his attitude to the disease is, what his beliefs and convictions are, and also the Degree in which he wishes them to be taken into account. At other times, the patient hides his intimacy and the Nurse will have to explore with delicacy what his convictions are so as not to at least hurt them. It has already been said that this exploration is unnecessary when the ailment barely scratches the surface of existence staff, but it is essential when the illness is long, painful or serious, particularly in a time like the present in which common ethical principles are no longer recognized by all and in which the demands of moral autonomism tend to be exorbitant. The status is very well described in recent guidelines, published in America, one of whose paragraphs I adapt to our context: ".... Nurses and patients often come from different cultures and differ in their concepts and ideas about the nature of the problem and what they wish to achieve. Patient care and the satisfaction of both parties are best served if the Nurse and the patient do not refuse to talk openly about their concerns and expectations."8.
In order to enter seriously, responsibly, into the interiority of her patient and for this greater Degree of personalization of her relationship with him to be valid, the Nurse needs to possess certain knowledge of people's convictions. The nurse is not obliged to be an expert in comparative religions or medical folklore. But it is in her interest to know the dominant cultural and religious factors in her environment that have a bearing on health or illness; she cannot carelessly neglect her obligation to know something about the customs and beliefs of her patients, as this is part of her professional skill . There is no shortage today, for example, of sources of information on the medical implications of different religious beliefs.9.
Negotiation phase. In the vast majority of cases, there is no conflict between the nursing care to be provided and the patient's convictions. There is a spontaneous coincidence of objectives that leads to cooperation without conflict. Should conflicts arise, the way should be open for sincere and open negotiation. It will often be good to count on the partnership of a priest or minister of the patient's creed, to help him/her discern what is imposed by the religious internship and what is result of superstition or ignorance. For their part, the Physician and the Nurse will never abuse their position of power and will abstain without absolute necessity from turning a given technical maneuver into a moral absolute. They will not forget that, in general, all clinical status is, by its very nature, tentative and provisional, and requires continuous modifications and trial and error for the Nurse-patient relationship to become a success. For such a negotiation to be deontologically correct, both parties should clearly, but without arrogance, show their respective points of view, consider them thoughtfully and with weight, and distinguish between those elements that are negotiable for both parties and those that are intangible.
Decision time. When the time comes to make decisions, these are made in the vast majority of clinical situations by mutual agreement or consensus. The patient's personal convictions and the doctor's or nurse's decision proposals then coincide, not by mere chance or adaptation, but by an alliance. It should not be forgotten that the patient's religious beliefs can play a very important positive role in the way in which he takes care of his health and copes with illness and old age, and in facilitating the relationship between the patient and hiscaregivers10, 11.
Deontology of polite disagreement. But in fact there are occasions when the patient's beliefs or convictions conflict or are incompatible with the interventions proposed by the doctor or nurse. This is inevitable in today's pluralistic society. It is therefore important to learn how to deal with them.
The phenomenology of these conflicts is well known. They occur most frequently in controversial moral areas or where the assertion of one's own autonomy takes on particular significance: interventions on reproduction (sterilization and contraception, abortion, assisted reproduction) and on behavior (neurosurgery, certain forms of psychopharmacology), but also when certain religious precepts are observed (refusal of blood transfusions, fasting rituals, exclusion of food or products from certain animal species, limitations imposed by the hospital environment on the observance of certain ritual practices). There are many occasions when adherence to certain myths or ideologies is so strong that patients or their guardians refuse medical treatment of the disease in order to entrust their cure to certain prayers, rites or manipulations.
Many of these problems, although from entrance they may seem insoluble and have no other way out than the rupture of the relationship between doctors, nurses and patients, must be carefully examined, to discern to what extent all those involved can walk together without harming their convictions. There is an ethical obligation to respect, in the event of conflict, the beliefs of those who have another religion or another worldview and to accede to their reasonable demands. A doctor or a nurse can never refuse to give in on what is not repugnant to reason or to his or her conscience, respectful of himself or herself and others.
It happens, however, that no matter how much she broadens her capacity to understand patients and wants to respond to their demands, the nurse will find herself in difficult situations, because it will not be possible for her to accede to certain demands of her patients or of the physician with whom she works without abjuring certain convictions, scientific or religious, which she holds as inalienable. Thus arises the scientific or conscientious objection. The nurse is a moral person who cannot be forced by any human authority, management assistant or professional, to act against her convictions. No matter how strong the pressure exerted by the health authority, by the doctor, by the patient or by the patient's relatives, the nurse cannot give in to demands that, after mature moral reflection, she judges irrational or that contradict her authentic beliefs.
There are groups or sects whose rites or precepts include practices that are repugnant to reason. There are degraded traditions or superstitions, counter-rational, to which the Nurse cannot yield, because they go beyond what, in her judgment and in the judgment of reasonable and prudent persons, can be granted as a gift of the autonomy of the persons. Many of these practices harm the patient or prevent him from receiving the necessary care to recover his health. The sick person adheres to them fiercely, not because of their intrinsic value, but because of their differentiating character in relation to the rest of society. This gives them a decisive and non-negotiable value, which fanaticizes those who profess them and makes them impervious to rational arguments.
Some patient groups can be easy victims of these fanaticisms. Children are one of them. The committee of Bioethics of the American Academy of Pediatrics has not long ago published a Statement on religious (I would say pseudo-religious) exemptions to child abuse legislation, to alert pediatricians to cases of seriously ill children, whose parents do not seek the benefit of proven effective medical treatments, but rely more on certain ritualistic or magical practices12. Cultural, ethical, legal and political issues such as the child's right to health, the ideological freedom of individuals, the obligation to protect the weakest, the right of parents to decide freely in favor of their children, etc., are intertwined in these situations in a very complex way. Another easily manipulated group is the one formed by patients with chronic pain or disability who seek in the so-called unorthodox parallel medicines a supplement or a substitute for the unsatisfactory treatments they receive from scientific medicine.
In any case, these situations of disagreement should be handled with propriety. Arrived at such a status , the Nurse and patient should politely break up, practice polite disagreement. It is not in accordance with the Ethics of respect that Nurse or patient add insult to disagreement. Dealing precisely with the status of incompatibility between the physician's and patient's views regarding unorthodox medicines, the American College of Physicians' Ethics guide describes very adequately the respectful climate of polite dissent: "(the nurse) ... should accept the (patient's) decision with patience and compassion, but may not participate in such treatment subject . Also (she) is a moral agent. She cannot be required to violate her own conscience. She cannot agree to do anything the patient wishes, particularly when it goes against (the Nurse's) moral convictions." To make it clear that the rupture is not with the person, but with the internship unacceptable in conscience, the Nurse will not fail to indicate to her patient, or in her case to the physician, that she is willing to resume the professional relationship in the whole very wide field of what is not repugnant to her conscience.
As the ethics of respect permeates professional relationships, the ethical sensitivity of patients and caregivers will be enriched. From what is published, one sometimes has the impression that in hospitals or doctors' offices a harsh confrontation is continually being waged between the autonomism of the patient, the paternalism of the doctor and the maternalism of the nurse. The various aspects of the three-way patient-nurse-physician relationship have already been analyzed to a greater or lesser extent, both theoretically and empirically.13. But we cannot forget that the mere characterization and refinement of the data does not necessarily mean the solution to the problem. The valid response to this permanent conflict must be sought in the well-formed and respectful conscience of those who make up the healthcare team, in mature reflection that takes into account the just aspirations of the patient, in the inspiring force of the deontological tradition, in a healthy notion of the latitude of straight moral solutions and in tolerance for what is required by the rational convictions of those involved in decision making. For conscience to be able to play its role as arbiter in an unbribable way, it is necessary for everyone to tenaciously refine their sense of what is right, implicit in the ethics of respect for others.14 and in the obligation to practice what is good15.
According to a widely disseminated opinion, the obligation of justice and the duty of beneficence are, together with the recognition of autonomy, the basic principles of contemporary biomedical ethics. If we were to apply these principles sincerely, that is, if we were not to interpret them in a utilitarian core topic , it would not be difficult for us to discover that respect for the convictions of others has a charitable dimension. For, on the one hand, to respect does not consist only in not interfering, in keeping out of the way, in accepting man as an end in himself and not degrading him to the condition of a means, as Kantian ethics demands. To respect is, in addition to all this, to honor, venerate and serve man in his transcendent dimension of imago Dei. This respect for God's workmanship in each person will sometimes lead us to care for the patient more than he, in the critical circumstances of the disease, can care for himself and to become respectful guardians of his authenticity, that is, of his capacity, weakened or suspended by the disease, to act in conformity with his genuine and profound convictions. There is no usurpation of autonomy here, because being faithful to oneself, being authentic, is an essential element of the internship ofautonomy16, 17. He would not be autonomous, because he would not be authentic, who, outside the extraordinary circumstance of a conversion, makes a choice that contradicts the deepest convictions he has professed until then, those that form the core of his moral personality.
The above has important consequences for our conduct. If, as is usual among us, the meeting Nurse-patient relationship takes place in the field of common convictions and both share the same religious faith, it would be hypocritical of the Nurse not to facilitate the patient's fidelity to these convictions and not to facilitate it to the extent proportionate to the overcoming of the human crisis that is every illness. As the Founder of our University points out, "Christian charity ... is directed, first of all, to respect and understand each individual as such, in his intrinsic dignity as a man and as a child of the Creator. "1818. 18 I think that there is a vast field for respectful cooperation between nurse and patient.
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