José Enrique Gómez-Álvarez1
1Facultad de Filosofía, Universidad Panamericana, Distrito Federal, México
Correspondence: José Enrique Gómez-Álvarez
Email: email@example.com; firstname.lastname@example.org
Received: November 3rd 2014
Judged: January 23rd 2015
Accepted: March 20th 2015
Discussions about ethics and reflections on the commitments and responsibilities of nurses regarding the care they provide to the patient, the family, or the community constitute fundamental questions in the interpellation of care practices. These discussions serve not only to investigate the meaning of the practice itself (questions arise, regarding why, for what and for whom is nursing care, as an object of study, and what is the best way of carrying it out), they can also be useful to question the sort of relation that the nursing professional establishes with patients, families or groups they look after in their health or disease processes.
Keywords: Nursing ethics; Nursing philosophy
Some definitions of ethics provided by philosophy are the framework for addressing levels of ethical reflection that coexist and are particularly relevant for understanding the phenomenon in the field of any discipline. From this perspective, it is worth making a distinction between ethics and morality.
Berbeglia says (quoted by Gazzotti):
... Morality is a specific cluster of rules and values that govern the behavior of a social group at a particular time and also establishes the punishment or reward of actions taken by its members. Ethics, meanwhile, is the secondary and derivative reflection, made by philosophies, based in part at least in the raw material of standards and values referred to, which serve as a springboard to uphold more universalizing and rationally founded theories.1
In philosophical terms, ethics consists of theming the ethos, defined as "a set of attitudes, beliefs or moral beliefs and behaviors of a person or social group".1 Each social group has its own code of rules and behaviors that are not parameters established once and for all, but are strictly related to the social and historical context to which they belong. In this regard, there are four levels of ethical reflection that coexist generating different ways of conceptualizing and understanding a moral problem:
I. Moral reflection, which is not strictly philosophical; rather, it is a spontaneous, uncritical, and unsystematic reflection that guides everyday decisions about what to do, to then act accordingly.
II. Normative ethics, which arises from the question, why should we do what we do? Maliandi argues that "when we see that not all are unanimous on what 'should be done'" and (in case some answer is gotten for that) the basic question of what one should do, and then that of, why does one do what one should do?, are the basis for philosophical ethics, which is the reconstruction of the principles governing moral life i.e. one tries to found a rule.2
III. Metaethics, which occurs when one "examines the validity of the arguments used for the foundation that carries out normative ethics. It establishes the meaning of the terms and ethical statements", i.e. when clarifications about meanings are demanded.2
IV. Descriptive ethics, which comes from outside the ethos, that is to say where one studies customs, regulatory codes, the beliefs of factual rules as to its structure and functioning, resulting in all that we judge cannot be changed (we act the way we act, we do what we do) things will continue as they are; or, in other words, the term "so-called facts of life." In contrast, there is the possibility that all those situations that can be changed over a wide range of action, could be different in the future if we act effectively. A primary responsibility in life is the one that allows us to make this distinction in a reasoned manner in all acts of our lifetime.1
In fact, all people who live in society operate on a moral knowledge, i.e., a set of unfiltered, unquestioned moral beliefs, codes of norms, and customs.
There is a fundamental principle known by the name of synderesis2,3 of ethics or morals according to philosophical materialism, the fundamental law or most general rule of all moral or ethical conduct, or, if preferred, the very content of synderesis could be stated as: "Do good and avoid evil" or, I act ethically or morally to the extent that my actions may contribute to the preservation of the existence of human subjects, myself among them, as acting subjects, who do not oppose, by their actions or operations, that same preservation of the community of human subjects. It is quite possible that most health professionals, if not all, would agree. However, the difficulty arises when specific questions are added about what is good, once confined to a space or the exercise of a particular profession, for example, nursing practice, with a variety of fields and stages for action, such as clinical, community, education, management, and research, among others. In all cases, the nurse must promote access and effectiveness of care for people and safeguard the principles that direct them such as solidarity, integrity, fairness and quality, in terms that refer to ethics, humanization, and knowledge necessary to be carried out in a manner that meets the care needs of individuals, families, and society.
Human vulnerability predisposes one to physical and spiritual suffering, that is, that human beings during an experience of illness are fragile, sometimes subjected to heat, cold, thirst, hunger, insecurity, failure, pain, and death. The disease can overcome the forces of human beings to care for themselves and for others, but it does not exceed the dignity of people and it should not be an obstacle to being recognized by those who have the job of caring. Ethical responsibility in care is based on the relationship and interaction with the person and family; its purpose must be to meet the needs with maximum benefits, minimal risks, and with respect for the rights of patients.
However, the development of current medical knowledge has led to intervening both in the life and death of people; in daily happenings, nurses face situations that pose dilemmas from the simplest to the most complex, for example, between the medical indication of invasive procedures and interventions with exposure to risk and damage.
Regarding the decision of the nurse in complex situations, there may be some other questions like, Is this procedure or intervention that I am doing good for the patient? You can reduce it still further, for example, would it be good to tell the truth about the risks of not protecting oneself with a condom, in front of his wife? In other words, rather than asking ourselves about the nature of good in the abstract, a long discussion, rather we take it to the practical field based on very general principles. In this case: I should not lie.
Now there are questions we ask and the answer (ethics) can be solved this way: Is it lawful to intervene without consent in a patient who is aware that this intervention is a painful procedure? The answer in the first instance is no. But there are occasions when our decision itself has implications for conflict. Conflict of values, of course. If you are trying to electrolytically stabilize a patient, you know with certainty that this is likely to create an imbalance that threatens his life, what do you do? This is an example of what moral perplexity means. Moral perplexity is not simply a state of doubt. Perplexity oscillates between the one and the other. But no one can settle down comfortably in contradiction. It must be resolved. The principles of perplexity are decision criteria in these cases. Its goal is to decrease evil or harm and promote good; these principles are often invoked to try to cope with extreme situations and make an ethical decision in which evil acts are present (Figure 1).5
Figure 1. Decision criteria according to the principle of moral perplexity
Among the principles of moral perplexity can be those of double effect and cooperation with evil (PCE). Cooperation is usually "working with another," and this may help people be more inclined to acts of malfeasance rather than beneficence, whether by influence of the will of the actor; by sharing in the action itself; or by facilitating or providing the ability to act. The practical utility of this principle, the ethical-decisional analysis of the nurse, is contrasted with Norma Oficial Mexicana NOM-019-SSA3-2013, for nursing practice in the Sistema Nacional de Salud, which aims to specify attributes and responsibilities to be met by nurses, according to legal provisions; by that logic, if "cooperation" means working with another in the implementation of an action, then by redefining the concept, cooperation with evil means working with another in the implementation of a morally wrong action.2,4
But the question still persists of what are the elements that allows one to value a human act as good or bad, that is, what are the circumstances, motivations, and moral object underlying the human act itself. Note that we do consider as 'good' actions within a profession that promote human development. Thus, we can ground the human goods in an ethical perspective as stated by Mc Intyre:6
Any list of obstacles and dangers must begin by mentioning the very lethal factors… predatory diseases... injuries, a faulty diet... we must add all the factors and conditions that pose a threat to development...
In other words, it is the actions that affect human flourishing that, as such, is a crucial element that has meaning in human dignity, not as living being, because if so, the aim of health sciences would be to maintain biological metabolism at all costs; what it is, is to keep the maximum expression of humanity of the patient; hence it is sometimes permissible to suspend clinical interventions that although they improve the patient's metabolism, insult him as a person.
From this perspective, an expanded definition of cooperation with evil is offered, which involves working (acting or supporting) with another person in performing an action with morally wrong object in certain mitigating or aggravating circumstances of moral damage, and with a specific intention of the cooperator, that somehow decreases the capacity of human development.
It may happen that we often meet complex situations before which one must make the decision about the greater good at the expense of the damage of its effects; for example, the events temporally associated with vaccination (ETAV)7 and the Manual of adverse events supposedly attributable to vaccination or immunization (AEFI).8
For that reason it is possible to cooperate with actions that we know pose a harm or evil (PCE), with the following restrictions:
To get a better understanding of the relationship with the human act of cooperating with evil in nursing practice, it is appropriate to comment on the scientific principles that guide it and what is considered good practice, a concept that is justified by the action in itself, that is to say the possibility of intervening technically with greater efficacy or effectiveness. From situations experienced in first-level care units and intensive care units (ICU), particularly in the latter, indications of treatment involve impairment to the patient's dignity. Of course the technical nature of the practice is unquestionable, the duty is to question the "good practice" in which cooperation with damage to the person coexists, to overcome the technological fact with that of mere metabolism.9,10
Due to the above, some questions arise, if the patient refuses treatment (in consciousness): Should we submit them to it? If I as a professional say that what is done is good practice based on clinical studies, is that enough for it to be accepted? Does this in fact it work for the good of the patient or does it turn (morally speaking) the other way?
Without trying to answer the above questions, Gutierrez et al.11 found that depersonalization is evident when the patient's right to dignified treatment is analyzed, and although 69 and 55% of nurses know that patients have the right to autonomy and privacy, it also turns out that that 70% say that the decision and privacy of the patient, and diagnostic and therapeutic offerings are not respected.
Undoubtedly nurses can ground abstract principles (utilitarian, deontologist, personalistic) in concrete actions. Of particular interest is the training of students to prepare them with an ethical stand and choice that requires more than the exercise of an innate or spontaneous ethics, or a speculative ethics with beautiful reasoning, but absent from a concrete practice to face real situations. Complex decisions that nursing professionals face daily should focus on the complexity of patients, critical care, collaboration and monitoring of medical treatments that call for a decision in situ, or sometimes an action that causes damage, just because they couldn’t avoid doing it.12,13
For example Silen et al. report that Swedish nurses suffering from burnout syndrome related to the ethical dilemmas faced in practice (moral perplexity). The authors cite the testimony of a nurse "Well, the classic case, I must say, is when a patient comes in and is in a bad way and can’t eat. Do you give no treatment, or do you put the patient on a drip and use a probe and all that? I think that’s dreadfully difficult"(Nurse 8) The nurse without expressing it technically speaks of the difficulty of applying the principle of synderesis, do good and avoid evil. Sometimes we cannot do the desirable good or to avoid evils.14
In connection with decision-making in accordance with the level of professional responsibility in nursing, the NOM-019-SSA3-2013,15 defines levels of complexity of nursing care as well as dependent, interdependent and independent nursing interventions (Figure 2).
Figure 2. Decisional algorithm based in NOM-019-SSA3-201 and principle of cooperation with evil.
According to the official rule defining the level of responsibility it is as follows:
High-complexity care: is that given to the patient requiring specialized care. Usually, it is in areas of specific attention, where care is often individualized, and it is helped by the use of advanced-technology biomedical equipment and nursing staff specialized in the relevant branch.
Low-complexity care: is that given to the patient in an alert and hemodynamically stable state, with minimum risk to life or recovery from a disease process. Care focuses on meeting needs of basic health and everyday life.
Medium-complexity nursing care: is that given to the patient in a disease process that does not require high technology; care is related to the degree of dependence on people to meet their health needs. The nursing staff needs to have knowledge and skills for comprehensive care of the patient, family, or community.
The ethical principles of moral perplexity, synderesis, and cooperation with evil is that although these principles do not refute a scientific model of evidence, they are essential in the practice of nursing professionals to strengthen their ethical stance in complex situations when they have to make decisions about patient care. In other words, we must ensure that the patient's dignity is above any other interest, achievement, or success of nursing interventions. Understanding PCE helps us to distinguish the means over the aims of the profession. It also improves the professional’s autonomy regarding the decisions they take. It is also worth noting that the level and type of decisions, qualitatively speaking, should be distributed according to the levels of responsibility as specified in the current regulations.