A nurse reflects on his reaction to the photographic essay and asks readers to do the same.

I have thought about my reaction to the photographic essay published in the May issue of Kai Tiaki Nursing New Zealand. I stand by my letter (p5) but I think my reaction, the reaction of others and the issues raised by the photographic essay are complex and deserve greater scrutiny.

When I opened Kai Tiaki Nursing New Zealand and saw the photo of the naked woman in the shower, my gut reaction was: "This is wrong, people should not be exposed to the public like this, it violates their dignity and privacy." However, given the high staff turnover (associated with the low wages and the poor status of caring) the reality for many elderly people in care is they have no choice about exposing themselves and their naked bodies to strangers. It could be argued the publication of the nude photos highlights the daily reality for some elderly people in care.

Informed consent

The second part of my reaction related to informed consent. I quickly turned the pages, looking for some evidence consent was sought and given. When I read residents (or their families) consented to taking and publishing the photos, I was not satisfied. I assumed the woman in the shower and the man on the commode were not competent to give informed consent for the publication of these photos. I am shocked I assumed these people where incompetent to make an informed choice about this matter. I have been researching preschool children for my PhD and have gone to great lengths to acknowledge and advocate preschool children's competence. The Code of Health and Disability Consumer Rights requires consumers to be presumed competent unless there are reasonable grounds for believing the consumer is not competent. Even where the consumer has diminished competence, the consumer retains the right to make an informed choice. On reflection, I had no objective information these people were not competent to give informed consent. Therefore, I must face my own ageist assumptions about the competence of frail looking elderly people to give informed consent. My letter to the co-editors argues good nursing respects personhood. The inclusion of faces in almost all of the photos humanises the images. To leave out the faces or cover them, as some news media have done, protects the person's anonymity but also serves to further objectify and dehumanise these people and the care depicted in the photos.

I have reflected on the fact these photos are of old bodies. We are exposed to images of young, particularly female bodies every day. While I think the objectification of women's bodies is wrong, I certainly do not write a letter to the editor of magazines every time it happens. Furthermore, on a regular basis nude infants and their bottoms are exposed to the public (in ads for nappies and other products) yet there is not a single outcry about informed consent or the inappropriate use of children's naked bodies to sell products. I think some of the reaction to the photos is related to the way our society idolises the youthful human body and cannot see the beauty in an aging body that has been an integral part of a life lived to the full.

Friends have asked me if I would like to be photographed nude or on the toilet, and whether I would want that to happen to my mother, father or grandmother. I would not. Perhaps if my experience regularly included exposing my naked body to strangers, I would be less concerned about having a nude photo taken and published. However, what I would like is of little relevance. Nurses need to be careful about imposing their assumptions on others. As Hughes and Farrow's point out, culturally safe nursing requires nurses to be aware of their assumptions and not base their care on their own socially and culturally constructed assumptions. (1) Furthermore, they suggest "what cultural safety asks us to do when we face a nursing situation outside our sphere of cultural experience is to "ask". (1) It is disappointing and ironic that in all the reaction to the photographic essay, few people have asked elderly people living in aged-care facilities for their views.

The power of pictures

A picture is said to be worth a thousand words and the power of pictures is evident in the reaction to the photographic essay. The Ministry of Health recently used powerful images of sick children suffering rare consequences of meningococcal disease to "inform" children about the meningococcal B vaccine. Some of these children went home terrified they would die or their legs would drop off if they didn't have the vaccine. Consequently, some parents felt they had no choice but to immunise their children. Was this an appropriate use of those images? Did it facilitate informed consent? NZNO publicly supported the meningococcal B immunisation campaign. I do not recollect any public reaction from nurses to this powerful use of images to influence vulnerable children and raise public perception of the risks of meningitis.

Some people will argue these images and their use are not comparable. The Ministry of Health had good intentions in using the photos and videos of sick children and the intention was to benefit children. I am sure photographer Alan Knowles, the sponsors and the co-editors of Kai Tiaki Nursing New Zealand had good intentions in publishing the photographic essay. Some will argue the benefit was to the carers and not to the elderly, but any improvement in the wages and conditions of those caring for the elderly should improve recruitment and retention of carers and therefore benefit the elderly in care. I have not been arguing two or more wrongs make a right, nor do I think the ends justify the means. I do think some good will come from the photographic essay, if people stop and critically reflect on why they have reacted the way they have to these images and not others. I have touched on a few issues raised by the photographic essay and people's reaction to it. I hope others will write about issues I know I have not dealt with and ones I may not have even considered.

Paul Watson, RN, BN (Hans), PhD Cand, is postgraduate programme leader at Christchurch Polytechnic Institute of Technology.

Reference

(1) Hughes, M., & Farrow, T. (2006).Preparing for cultural safety assessment. Kei Tiaki Nursing New Zealand: 12: 1, 12 14.