The purpose of this article is to examine whether patient/client autonomy is always compatible with the nurse’s role of advocacy. The author looks separately at the concepts of autonomy and advocacy, and considers them in relation to the reality of clinical practice from professional, ethical and legal perspectives. Considerable ambiguity is found regarding the legitimacy of claims of a unique function for nurses to act as patient advocates. To act as an advocate may put nurses at personal and professional risk. (...) It may also be deemed arrogant and insulting to other health care professionals. Patient autonomy can be seen as a subcategory of the right of every individual to self-determination, and as such is protected by law. However, it is questionable whether the traditionally paternalistic approach to health care provision truly respects the autonomous rights of each patient. The author considers examples and cases from the literature that resulted in professional and/or personal difficulties for the nurses involved, and also reflects on an incident from her own practice where a positive outcome was achieved that demonstrated compatibility between the concepts under consideration. (shrink)

This paper raises the questions: 'What do we expect from nursing ethics?' and 'Is the literature of nursing ethics any different from that of medical ethics?' It is suggested that rather than develop nursing ethics as a separate field writers in nursing ethics should take a lead in making the patient the central focus of health care ethics. The case is made for empirical work in health care ethics and it is suggested that a good way of setting about this (...) is to ask practising nurses about the real ethical problems they encounter. (shrink)

How do physicians handle informing patients of their diagnoses and how much information do patients really want? How do registered nurses view both sides of this question? Three questionnaires were constructed and administered in a mid-size hospital in New York state. Physicians and nurses underestimate the number of patients who want detailed information. Patients who earn more than average, have a college education, and who are under age 60 are more likely to want information, and state that their physician should (...) give it to them. Only 42% of physicians state that patients want a detailed description of their diagnosis and treatment options. Physicians educated outside the USA appeared to be more likely to change their criteria for informing patients and, along with American-educated nurses, were more willing to participate in formal discussions of the issue. Physicians should comply with the wishes of patients for information and include them in the team deciding on diagnosis and treatment. (shrink)

A medical centre is an institution established for a specific purpose: to facilitate the health and health-related welfare of the medical centre's patients. Within this institution, there are a variety of professionals who act and interact to serve this purpose. Of particular interest is the interaction between physician and nurse. Generally, the nurse is thought to be under a certain obligation to implement a physician's orders unless there is good reason not to do so. This qualifier places a conflicting obligation (...) upon the nurse not to implement some physician orders. How should a judgement about which orders there is 'good reason' not to implement be made? I propose to approach this question through an analysis of the obligation the nurse has to implement the order of a physician, and the conditions under which the order does not pose such obligations. This analysis will consist of an examination of the obligation in terms of the purposive authority of the physician. For example, in the context of the medical centre, the physician's medical training qualifies her as best able to make determinations of what treatment would promote the patient's health. However, this purpose not only serves as the basis of the physician's authority, but also serves as a limitation upon the physician's authority (for example, an order which would harm the patient would not reflect the purpose for which the physician has been given authority). Thus, a philosophical investigation into the nature of the obligation to implement a physician's orders can help to clarify those occasions when a nurse should not implement an order. (shrink)

Dilemmas about resuscitation and life-prolonging treatment for severely compromised infants have become increasingly complex as skills in neonatal care have developed. Quality of life and resource issues necessarily influence management. Our Institute of Medical Ethics working party, on whose behalf this paper is written, recognises that the ultimate responsibility for the final decision rests with the doctor in clinical charge of the infant. However, we advocate a team approach to decision-making, emphasising the important role of parents and nurses in the (...) process. Assessing the relative burdens and benefits can be troubling, but doctors and parents need to retain a measure of discretion; legislation which would determine action in all cases is inappropriate. Caution should be exercised in involving committees in decision-making and, where they exist, their remit should remain to advise rather than to decide. Support for families who bear the consequences of their decisions is often inadequate, and facilitating access to such services is part of the wider responsibilities of the intensive care team. The authors believe that allowing death by withholding or withdrawing treatment is legitimate, where those closely involved in the care of the infant together deem the burdens to be unacceptable without compensating benefits for the infant. As part of the process accurate and careful recording is essential. (shrink)

This paper develops a model of the nurse/physician authority relationship presented in an earlier issue of this journal, and responds to criticisms raised against that model in commentaries on that article. Specifically, I examine the discrepancy which exists between medical knowledge and nursing education, and show this discrepancy to be a difference in type, not quality. The implication is that improvements in nursing education will not affect the authority relationship between physician and nurse. To affect this relationship the nature of (...) nursing education must change. (shrink)