It is not unusual for the adjective ‘vulnerable’ to be applied to those in receipt of nursing practice without making clear what it is that persons thus described are actually vulnerable to. In this paper I argue that the way nursing has adopted the idea of vulnerability tends to imply that some people are in some way invulnerable. This is conceptually unsustainable and renders the idea of the vulnerable patient meaningless. The paper explores the meaning of vulnerability both in general (...) terms and in the context of nursing practice. It is argued that to be in receipt of nursing is to become, to a greater or lesser extent, more‐than‐ordinary vulnerable. Thus all patients are more‐than‐ordinarily vulnerable and this restricts their potential to flourish. Nurses are well placed to contribute to the flourishing of more‐than‐ordinarily vulnerable persons and my substantive claim is that this ‘protective’ function is indeed a legitimate and fundamental part of the role of nurses. (shrink)

I argue to a conclusion I find at once surprising and intuitive: although many considerations show trust useful, valuable, important, or required, these are not the reasons for which one trusts a particular person to do a particular thing. The reasons for which one trusts a particular person on a particular occasion concern, not the value, importance, or necessity of trust itself, but rather the trustworthiness of the person in question in the matter at hand. In fact, I will suggest (...) that the degree to which you trust a particular person to do a particular thing will vary inversely with the degree to which you must rely, for the motivation or justification of your trusting response, on reasons that concern the importance, or value, or necessity of having such a response. (shrink)

This article gives an overview of the nursing ethics arguments on euthanasia in general, and on nurses' involvement in euthanasia in particular, through an argument-based literature review. An in-depth study of these arguments in this literature will enable nurses to engage in the euthanasia debate. We critically appraised 41 publications published between January 1987 and June 2007. Nursing ethics arguments on (nurses' involvement in) euthanasia are guided primarily by the principles of respect for autonomy, nonmaleficence, beneficence and justice. Ethical arguments (...) related to the nursing profession are described. From a care perspective, we discuss arguments that evaluate to what degree euthanasia can be considered positively or negatively as a form of good nursing care. Most arguments in the principle-, profession- and care-orientated approaches to nursing ethics are used both pro and contra euthanasia in general, and nurses' involvement in euthanasia in particular. (shrink)

The cause of ethical failure in organisations often can be traced to their organisational culture and the failure on the part of the leadership to actively promote ethical ideals and practices. This is true of all types of organisations, including the professions, which in recent years have experienced ongoing ethical problems. The questions naturally arise: what sort of professional culture promotes ethical behaviour? How can it be implemented by a profession and engendered in the individual professional? The answers to these (...) questions are of interest to business ethicists since the causes of ethical problems in business are often the same and the professions, as ethically challenged organisations, make useful and informative analogues for the measures to be adopted or avoided when the attempt is made to raise the ethical standards of business.Given this focus on the professions, it will be argued that the usual, direct attempts to control unethical behaviour by using codes of ethics, legislation and self-regulatory regimes, are not successful. (shrink)

The general expectation that patients should be willing to trust nurses is rarely explored or challenged despite claims of diminishing public trust in social and professional institutions. Everyday meanings of trust take account of circumstance and suggest that our understanding of what it means to trust is contextually bound. However, in the context of health care, to trust implies a particular understanding which becomes apparent when abuses of this trust are reported and acknowledged as scandals. The predominant assumption in the (...) literature that trust is something that occurs between equally competent adults cannot explain trust in nursing precisely because of the unequal power relationships between patients on the one hand and healthcare professionals on the other. Moreover, the tendency to conflate terms such as trust, reliance, confidence and so on suggests that confusion permeates discussions of trust in nursing. In this paper, I argue in support of Annette Baier’s requirement of good will (or lack of ill will) as the essential feature of trust, and outline how this account (i) enables us to make the necessary distinctions between trust on the one hand and ‘trust pretenders’ on the other; and (ii) lays the foundations for understanding trust in relationships, such as those between patients and nurses, where power differentials exist. (shrink)

Explorations of a trust approach for nursing ethicsTrust has long been acknowledged as central to nurse–patient relationships. It, however, has not been fully explored nor‐matively. That is, trust must be examined from a perspective that encompasses not only reliability and competence, but also good will within nursing relationships. In this paper, we explore how a trust approach, based on Annette Baier’s work on trust in feminist ethics, could help inform future developments in nursing ethics. We discuss the limitations of other (...) approaches such as those based on contracts, paternalism, and care. By drawing out central features of Baier’s theory, we demonstrate how it can help overcome the problems of these previous models. In doing so, we emphasise the importance of combining the ethics of care and justice, acknowledging vulnerability and the potential for evil in nursing relationships, and politically situating the ethical concerns of nursing. (shrink)

The idea that nurses should be trustworthy seems to be accepted as generally unproblematic. However, being trustworthy as a nurse is complicated because of the diverse range of expectations from patients, relatives, colleagues, managers, peers, professional bodies and the institutions within which nursing takes place. Nurses are often faced with competing demands and an action perceived by some as trustworthy can be seen by others as untrustworthy. In this article some of the reasons for the importance of being trustworthy are (...) offered together with a preliminary discussion about how being a trustworthy nurse is far from straightforward. (shrink)

: Discussions of ethical approaches in nursing have been much enlivened in recent years, for instance by new developments in the theory of care. Nevertheless, many ethical concepts in nursing still need to be clarified. The purpose of this contribution is to develop a fundamental ethical view on nursing care considered as moral practice. Three main components are analyzed more deeply--i.e., the caring relationship, caring behavior as the integration of virtue and expert activity, and "good care" as the ultimate goal (...) of nursing practice. For the development of this philosophical-ethical interpretation of nursing, we have mainly drawn on the pioneering work of Anne Bishop and John Scudder, Alasdair MacIntyre, Lawrence Blum, and Louis Janssens. We will also show that the European philosophical background offers some original ideas for this endeavor. (shrink)

This paper examines the concept of 'professional trust' and argues that trust is an essential component of what it means to be a 'professional'. The first part of the paper discusses the nature of trust in general and attempts to establish two main points: that we are all involved in relationships of trust and that all trust involves risk. The second section examines the idea of professional trust and draws on an analysis of knowledge provided by Michael Oakeshott that divides (...) knowledge into two components, 'information' and 'judgment'. The central argument is that the exercise of judgement through the possession of 'discretionary powers' is central to being a professional, but that judgement itself resists reduction to propositional formulation because it is essentially tacit and individual. The paper's focus is fairly narrow and does not examine, for example, the role of trust in teacher--pupil relationships, how trust may be related to learning or the role of trust in the pursuit of collaborative educational research. (shrink)

Our study provides a review of argument-based scientific literature to address conscientious objections to end-of-life procedures. We also proposed a taxonomy based on this study that might facilitate clarification of this discussion at a basic level. The three clusters of our taxonomy include (1) nonconventional compatibilists that claim that conscientious objection against morally repugnant social conventions is compatible with professional obligation, (2) conventional compatibilists that suggest that conscientious objection against social convention is permissible under certain terms of compromise, and (3) (...) conventional incompatibilists that aver that conscientious objection is incompatible with the privileges and obligations of a health care provider. We conclude with three moments of reflective pause. The first pause reflects on the question of the health of a society's pluralism. The second pause results in suggested practice guidelines for conscientious objection to facilitate cooperation. The final pause reveals the need for further research to uncover a global perspective. (shrink)

I explore Baier, Held, Okin, Code, Noddings, and Eisler on trust and distrust. This reveals a need for reflection on the analysis, ethics, and dynamics of trust and distrust-especially the distinction between trusting and taking for granted, the feasibility of choosing greater trust, and the possibility of moving from situations of warranted distrust to trust. It is impossible to overcome the need for trust through surveillance, recourse to contracts, or legal institutions.

This paper explores the nature of trust in nurse–patient relationships from the perspective of the patient's trust in the nurse and what might be said to then render such a relationship trustworthy, from the patient's point of view. The paper commences with a general examination of the nature of trust, followed by consideration of the nature of professional–patient relationships in healthcare, with emphasis on nurse– patient relationships in particular. The nature of this relationship is used to provide grounds for arguing, (...) both morally and conceptually, that the nature of patients’ trust in those who nurse them is generally such that for the nurse to respond in a trustworthy way, she must care about her patients, not just for them. In arriving at this conclusion, the paper deliberately restricts its focus to nurse–patient encounters where patients are adults and a relationship, as opposed to a brief engagement between two people, can be said to have taken place. The context for this focus is public sector health care in the United Kingdom. In the text, gendered pronouns referring to doctors, nurses and patients are meant to be inclusive of both sexes. (shrink)

Providing good care requires nurses to reflect critically on their nursing practices. Ethics education must provide nurses with tools to accomplish such critical reflection. It must also create a pedagogical context in which a caring attitude can be taught and cultivated. To achieve this twofold goal, we argue that the principles of a right-action approach, within which nurses conform to a number of minimum principles, must be integrated into a virtue ethics approach that cultivates a caring attitude. Ethics education that (...) incorporates both the `critical companionship' method and the use of codes of ethics contributes positively to cultivating critical reflection by nurses. (shrink)

Most incidences of dishonesty in research, financial investments that promote personal financial gain, and kickback scandals begin as conflicts of interest (COI). Research indicates that healthcare professionals who maintain COI relationships make less optimal and more expensive patient care choices. The discovery of COI relationships also negatively impact patient and public trust. Many disciplines are addressing this professional issue, but little work has been done towards understanding and applying this moral category within a nursing context. Do COIs occur in nursing (...) and are they problematic? What are the morally appropriate responses to COI for our discipline and for individual practicing nurses? In this paper I examine the nature of 'conflict of interest' as a general ethical category, its characteristics and its application to our discipline. Conflict of interest is an odd moral category that may actually or potentially result in immoral decisions. The moral justification for COI is grounded prime facie by the moral value of respect for persons and principle of fidelity from which trust is developed and maintained. In review of the historical development, there appears to be consensus on some qualities of COI that are presented. I conclude that making judgements about COI are challenging and often difficult to determine from a nursing perspective. Improving nurses' and professional organizations' awareness of COI and sharpening our ability to respond appropriately when COI arise can reduce potential harm and promote trust in those whom we serve. (shrink)

The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide (...) a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)

This paper explores the nature of trust in nurse–patient relationships from the perspective of the patient's trust in the nurse and what might be said to then render such a relationship trustworthy, from the patient's point of view. The paper commences with a general examination of the nature of trust, followed by consideration of the nature of professional–patient relationships in healthcare, with emphasis on nurse– patient relationships in particular. The nature of this relationship is used to provide grounds for arguing, (...) both morally and conceptually, that the nature of patients’ trust in those who nurse them is generally such that for the nurse to respond in a trustworthy way, she must careabouther patients, not justforthem. In arriving at this conclusion, the paper deliberately restricts its focus to nurse–patient encounters where patients are adults and a relationship, as opposed to a brief engagement between two people, can be said to have taken place. The context for this focus is public sector health care in the United Kingdom. In the text, gendered pronouns referring to doctors, nurses and patients are meant to be inclusive of both sexes. (shrink)

Although we theorize that nurses ‘make a difference’ to patient outcomes and speculate that this happens because nurses ‘care’, there is so far little evidence to support this nebulous claim. Efforts to promote care as the defining characteristic of nursing, and an ‘ethic of care’ as the ethical basis of nursing, have sparked debate within the discipline. This debate has resulted in a polarization that has effectively stalled productive discourse on the issues. Moreover, the focus on care has been at (...) the expense of understanding the true nature of the relationship between caring and the broader base of ethical knowledge that underpins nursing and that must underpin nursing if it is a viable practice profession. This paper used the framework of philosophical argument to explore the moral and ethical foundations of nursing from the perspective of personal and public morals, and responsive nurse–patient relationships as the reflection of ethical nursing knowledge. The foundation of ethical nursing knowledge is the personal moral sense that resides within the individual and that nurses hold in common with others. Personal moral knowledge is transformed into disciplinary ethical knowledge specific to nursing through disciplinary consensus. Responsive relationships are conceptualized in the nursing literature as founded on three essential elements: respect, trust, and mutuality. These three elements are grounded in ethical nursing knowledge; therefore responsive nurse–patient relationships reflect both personal moral knowledge and disciplinary ethical knowledge. By facilitating the articulation of ethical nursing knowledge in practice, responsive relationships connect theory, ethical knowledge, and clinical outcomes. (shrink)

This article discusses findings from a mixed method literature review that investigated cancer patients’ perceptions of what constitutes a good nurse. To find pertinent articles, we conducted a systematic key word search of five journal databases (1998—2008). The application of carefully constructed inclusion criteria and critical appraisal identified 12 relevant articles. According to the patients, good nurses were shown to be characterized by specific, but inter-related, attitudes, skills and knowledge; they engage in person-to-person relationships, respect the uniqueness of patients, and (...) provide support. Professional and trained skills as well as broad and specific nursing and non-nursing knowledge are important. The analysis revealed that these characteristics nurtured patient well-being, which manifests as optimism, trust, hope, support, confirmation, safety and comfort. Cancer patients’ perceptions of what constitutes a good nurse represent an important source of knowledge that will enable the development of more comprehensive and practice-based views on good nursing care for such patients. These perceptions help us to understand how nurses effectively make a difference in cancer patient care. (shrink)

This article considers the foundation of nursing as a moral practice. Its basic claim is that all nursing knowledge and action reside on a moral foundation. The clinical gaze meets vulnerability in the patient’s human condition. To see a patient’s wound is to see his or her hurt and discomfort; it is a concerned observation. To see the factual and pathophysiological is at the same time to see the ethical: the moral realities of suffering, pain and discomfort. A nurse’s emotional (...) sensitivities are central to understanding a patient’s experiences of illness. Emotions reveal value and ascribe moral importance to certain situations; they are addressed centrally by vulnerability and the moral realities of illness. Hence, the essence of nursing knowledge and nursing performance cannot be understood merely as ontology (i.e. as being-with-the-other). Nursing is basically being-for-the-other; it is responsibility; it is ethics. (shrink)