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Case Studies in Nursing Ethics.

"The first and most helpful criticism I ever received from a doctor," wrote Sarah Dock in the American Journal of Nursing in 1917, "was when he told me that I was supposed to be simply an intelligent machine for the purpose of carrying out his orders." No one familiar with modern nursing can accept this characterization. Far from being handmaiden to the physician, the contemporary nurse must be able to think and act for herself. As Lewis Thomas has pointed out, nurses now occupy the central role in the modern teaching hospital: "They deserve more respect and attention from everybody (and much more pay)" (New York Review of Books, September 24, 1987). What has not been so widely recognized, however, is the extent to which nurses must also make complex ethical decisions. The practice of nursing requires independent ethical reasoning and analysis, as made clear by the 115 detailed case studies presented here by Veatch and Fry.

Roughly patterned on Veatch's pioneering Case Studies in Medical Ethics (Harvard, 1977), Case Studies in Nursing Ethics is divided into three parts. The first uses a variety of cases to indicate that nursing practice is inextricably value-laden. Part II draws on additional cases to identify and illustrate the application of various principles--for example, justice, autonomy, veracity, and fidelity--in analyzing ethical dilemmas in nursing. Part III provides opportunities to examine and apply these principles to issues such as abortion, mental illness, experimentation on humans, informed consent, and refusal of treatment.

The case studies are a treasure. Nearly all are based on real situations experienced by one of the authors or shared with them by practicing nurses. The cases are extremely well written and sharply focus relevant ethical considerations in a wide range of contexts. Each case is followed by a commentary in which Veatch and Fry, in a clear, even-handed manner, provide important background information and try to ensure that all relevant lines of argument, distinctions, and possible objections are identified. The commentaries are often Socratic in the sense of tracing implications of certain positions and raising possible objections to different alternatives so as to provoke further reflection. Used in the classroom by a skilled and experienced instructor (or to focus hospital case conferences or panel discussions), the individual case studies and commentaries are a valuable resource.

As a whole, however, the book may present a somewhat misleading picture of ethics in general and of ethics in nursing. The concentration on complex dilemmas, together with the tendency of the commentaries to identify good arguments for and against various alternatives and then to leave the final decision up to the reader, reinforces the widespread (but mistaken) belief that ethics is, at bottom, "just a matter of opinion." Ethics teachers are all too familiar with this vulgar form of relativism. One of the est ways to disarm it is to show that while there are very difficult cases where the application of principles, evidence, and argument is inconclusive, there are also cases where ethical reasoning and analysis converge on a single solution, as well as cases where we can sometimes distinguish more justifiable from less justifiable positions, even though the better positions are not entirely free from difficulty and the worse are not entirely wrong-headed. Veatch and Fry emphasize cases at the difficult end of the spectrum, which are, of course, the more interesting cases. But unless guided by a skilled and experienced instructor, readers of this book are likely to infer that, when all of the smoke has cleared, ethics is still simply "a matter of opinion." The authors may have been able to prevent this impression by including a more generous sprinkling of less complex, though nonetheless representative, cases and indicating how ethical reasoning and analysis can also lead to well-grounded resolutions.

Veatch and Fry should also have paid a bit more attention to the historical, sociological, and political dimensions of nursing ethics. They overemphasize quandaries of individual decisionmakers and downplay the ambiguous relationship between nurses and physicians and the various hierarchical-organizational constraints that make ethical autonomy in nursing problematic. Notions that play an important role in nursing ethics, though not perhaps in physician ethics or biomedical ethics generally, are correspondingly underemphasized. More direct attention should have been given to such matters as nursing autonomy and integrity, nurses' relationships with physicians, the possibility of compromise conscientious refusal, whistle-blowing, structural change, political action, and nursing strikes. The authors may, in this connection, have been overly influenced by the structure and orientation of Case Studies in Medical Ethics, especially in Part III, where their emphasis is on biomedical ethics generally and not on the special situation of the nurse.

Still, this is a fine volume and a much needed addition to the developing literature of nursing ethics. My advice to nursing educators planning to use it in the classroom is to acquire more background in ethical resoning and analysis than is provided by the book itself. My recommendation to ethics teachers considering its use is to examine the work of Christine Mitchell, Gerald Winslow, Andrew Jametown, Mila Aroskar, and others to learn more about the history, sociology, and politics of nursing. Although Sarah Dock's image of the nurse as an "intelligent machine" is, at best, obsolete, the legacy lingers. One ought to know why this is so and recognize that individual nurses and the profession as a whole still must contend with it.

Martin Benjamin is professor of philosophy at Michigan State University, East Lansing, MI.
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Author:Benjamin, Martin
Publication:The Hastings Center Report
Article Type:Book Review
Date:Apr 1, 1988
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