Brandon Hostler’s arm is usually among the first extended for the annual flu shot at Ruby Memorial Hospital in Morgantown, W.Va. He is, after all, a registered nurse — he knows it can do some good.

But if that shot ever becomes mandatory, he will balk.

“I wouldn’t quit or switch jobs,” he said. “But we are health care professionals. We know the risks and the benefits, and to force us to do something like that and not have a say in it, I think it would be offensive and unwanted.”

This story nicely points out two different facets of one of the most important values in the world of healthcare, namely autonomy.

Why is autonomy important? On one hand, it is important for its own sake. We simply value the ability to choose for ourselves. On the other hand, we value autonomy because we generally believe that when people choose for themselves, they will choose better than when others choose for them. Both of those facets of autonomy appear in the story above. Some nurses are hesitant about the flu shot because they’re uncertain about whether the risks are worth the benefits; others think the benefits are there, but still want the freedom, for its own sake, to say “no thanks.”

But there are also limits on autonomy. And in particular, membership in a profession brings a whole bunch of such limits. The benefits of professionalism involve a kind of quid pro quo — society asks things in return. The hard question, of course, is whether any particular limit on autonomy — such as mandatory flu shots — is or should be part of that bargain.

From the Wisconsin State Journal: “Nurse disciplined for using donor program credit card for personal use”

A registered nurse who used a Neenah hospital’s organ donor program credit card to take cruises and vacations with her husband has been disciplined by the state Board of Nursing.

The board suspended the license of Peggy Grambsch, of Poy Sippi, for six months on Jan. 26. It also ordered Grambsch to take a nursing ethics course and pay $750….

It’s hard to blame the board for requiring that Grambsch take an ethics course. But it’s hardly likely to be the right remedy here. First, the behaviour she engaged in is, as far a I can see, a matter of outright criminality, rather than subtly unethical behaviour. Secondly, to the extent that there are ethical issues here — misappropriation of funds is of course unethical, in addition to being illegal — I suspect such issues are not covered in most nursing ethics courses. If I were on that board, I would have insisted on a business ethics course, especially one with a section on financial integrity and ethics in the workplace.

From the Wall Street Journal: Helping Nurses Cope With Compassion Fatigue

New programs are underway to help nurses cope with compassion fatigue, an occupational hazard for caregivers that also puts patients at risk of substandard care….

Though the intense emotional demands on nurses are as old as the profession itself, researchers have only in recent years begun to study the effects of compassion fatigue, a form of burnout compounded by secondary traumatic stress….

It’s good to see that this article discusses the impact of compassion fatigue not just on nurses, but also on patients. But of course, while impact on patient care is the ‘trump card’ of the world of healthcare, it shouldn’t be forgotten that institutions of all kinds have a fundamental obligation to safeguard the mental and emotional health of employees.

See this recent story: Patient Dies During Hospital Labor Dispute

California authorities are investigating the death of a patient at an Oakland hospital that police and hospital and union officials said resulted from a medication error made during a labor dispute between nurses and the health system that runs the hospital.

Police and officials at Alta Bates Summit Medical Center told the local media the woman died after she received an incorrect dose of medication administered by a replacement nurse. At the time, regular staff nurses employed by Sutter Health System were locked out following a one-day strike by 23,000 nurses across the state….

A couple of things differentiate labour disputes in healthcare from labour disputes in, say, the auto industry. One is that in healthcare, the “labourers” tend to be licensed professionals, subject to a code of ethics, etc.

The other difference is that, in healthcare, there’s always a shared focal point for ethical argumentation, namely the patient. Both sides in a healthcare labour dispute have to put some of their most central arguments in terms of patient wellbeing. In the auto industry, by comparison, there’s much less common ground. Sure, both GM and the UAW have an interest in making sure the company stays in business. But beyond that, it’s “us vs. them.” Every dollar gained by the workers is a dollar lost by someone else (managers, shareholders, etc.) In healthcare everyone has to bow to patient interests. You can be as cynical as you want about the other side, but you still know that, in public at least, the arguments they give must give priority to patient wellbeing.

One final note: an ethicist quoted in the story above blames inadequate compensation for troubles like this. I’m skeptical about that. I don’t doubt that wages are an issue. But higher wages wouldn’t necessarily mean fewer labour disputes. You would likely still see the regular cycle of negotiation, strike, contract, period of calm, and then renewed negotiations. And so on. And after all, wages aren’t the key issue in the eyes of nurses, are they? What do you think?

See this story, from the BBC: RCN wants longer hospital visiting hours

Hospital visiting times should be extended so patients’ relatives can become more involved in their care, the Royal College of Nursing has said.

RCN head Peter Carter said he did not want relatives performing tasks nurses were employed to carry out, but that there were “real benefits” for patients when family members helped with care.
…
But patients’ groups warned such a move could be “the tip of the iceberg”….

Make sure to read the comments under the BBC story — they reveal lots of additional reasons for and against extending visiting hours.

What do you think?

Hers is a bottom-up, biological story, but, in her telling, it also has implications for ethical theory. Morality turns out to be not a quest for overarching principles but rather a process and practice not very different from negotiating our way through day-to-day social life. Brain scans, she points out, show little to no difference between how the brain works when solving social problems and how it works when solving ethical dilemmas.

Churchland thinks the search for what she invariably calls "exceptionless rules" has deformed modern moral philosophy. "There have been a lot of interesting attempts, and interesting insights, but the target is like perpetual youth or a perpetual-motion machine. You're not going to find an exceptionless rule," she says. "What seems more likely is that there is a basic platform that people share and that things shape themselves based on that platform, and based on ecology, and on certain needs and certain traditions."

The upshot of that approach? "Sometimes there isn't an answer in the moral domain, and sometimes we have to agree to disagree, and come together and arrive at a good solution about what we will live with.”

The point I found most interesting, reading the review, was that Churchland feels that the emphasis on finding "exceptionless" moral rules is futile. According to her, we should place more emphasis on how we can agree to disagree rather than consistently search to find "exceptionless rules" to apply in difficult moral dilemmas.

She makes a good point and one that many of us should consider. Think of the many times we are faced with moral dilemmas in the context of nursing. Often the most effort goes into attempts to make others see situations from our perspective, and to agree with us. Frequently we hear statements like, "This should never happen" or "We should not allow this in any case" when our colleagues, patients and families are discussing difficult moral issues, like end-of-life care or allocation of scarce resources. These kinds of expressive statements, such as "I believe X is wrong" (instead of “X”, substitute any contentious bioethics concept such as: abortion, euthanasia, harm reduction), reflect a kind of "exceptionless" stance. When we approach difficult moral dilemmas with this kind of a stance, we typically are, in fact, looking for others to agree with us and align with our values to justify an "exceptionless rule" of sorts. However, it's clear that this is almost impossible in diverse societies and groups in which a broad range of values exist.

We accept diversity in many kinds of everyday health care situations and out of that acceptance arises our role of advocate and facilitator. For example, a patient may not wish to take a prescribed sleep aid, may refuse physiotherapy or may wish to delay a procedure. As nurses, we advocate for the choices and wishes of our patients and we try to facilitate their decision-making. We often allow patients to make choices that we perhaps would not make ourselves or that we would not support if we were the only decision-makers. This is part of respecting the autonomy of others and is a straightforward value in nursing and health care. However, when dealing with more difficult or challenging dilemmas, we tend to turn first to our own values and beliefs instead of first trying to consider the different values of others. This isn’t unusual and is a response many have when faced with morally challenging situations: we turn to our own consistently-held values and beliefs in a search for an anchoring answer. In other words, in simple day-to-day health care situations, we often quite easily accept that patients will make choices that reflect different values and beliefs than ours and in turn, we respect those diverse decisions. In more serious or morally challenging situations, however, we may find ourselves turning instead to our own values and beliefs to determine what the “right” option should be.

Churchland notes that trying to find answers to difficult moral problems is just like trying to find our way through less challenging, day-to-day social problems. As she notes, brain scans show very similar activity when sorting out everyday problems or working through serious and difficult moral dilemmas. For many of us, it is perfectly acceptable to “agree to disagree” on the food a patient may eat, the time for a procedure to be done, scheduling therapy or taking a sleeping aid. However, when faced with a patient who is, for example, seeking euthanasia or an abortion for a reason with which we may not agree, many nurses find it disturbing, upsetting and often distressing to care for patients whose values and beliefs, in this context, may be much different than their own. Churchland would likely say that trying to seek alignment of values, in difficult cases like this is neither satisfying or possible and that we should not focus so much attention on trying to do so.

The review in the Chronicle is a thorough one, highlighting a number of other key points in Churchland’s work. I haven’t read the book yet so it’s difficult to comment too much on her views, as noted by the reviewer, without reading about them firsthand, so I will read the book and, hopefully, will review it here as well.

The point that struck me was that we don’t really think enough (or at all!) about how we approach moral dilemmas. In nursing, these kinds of dilemmas arise often unexpectedly or quickly and must be dealt with in the moment. We expend a majority of our emotional and working energy trying to sort through a few incredibly challenging problems but often don’t take the time to reflect upon “how we did” and whether we were simply seeking an “exceptionless rule”, i.e. seeking the alignment of others with our own values rather than trying to find a more middle-of-the-road moral ground that everyone can live with. In terms of expending our energy, doing so to understand just a little better the way we’re wired as well as the way we react to and process these kinds of difficult moral dilemmas makes good sense.

See this story by James Warren for the New York Times: Finally, Nurses Are Set to Vote on Unionizing

The American Federation of State, County and Municipal Employees is still at it and will finally get a representation election next Wednesday and Thursday among about 270 registered nurses at one of the group’s locations, Our Lady of the Resurrection Medical Center.

It’s a drawn-out, nearly decade-long tussle fit for the times. The union has met resistance and filed 50 complaints about unfair labor practices with the National Labor Relations Board. The company voluntarily settled 18 of the 50 complaints brought against its various properties before any federal hearing….

Interestingly, Warren’s article makes absolutely no mention of the fact that nurses are not just regular employees, that they are health professionals. Nurses are licensed professionals with a code of ethics and an avowed commitment to the public good. That makes them pretty different from municipal employees or auto workers. That’s not to say that they shouldn’t unionize. But it does raise concerns about nurses joining unions that are not exclusively unions of nurses. Unionization has a purpose, and unions have their goals. But the goals of a union can quite easily conflict with the goals to which a health professional swears upon joining the profession.

See this editorial by Theresa Brown, for the NY Times: Physician, Heel Thyself

…while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

Of course, as Brown recognizes, the issue is much more complex than simply ‘MD vs RN.’

…because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

But even this puts too much emphasis on the behaviour of doctors; I strongly suspect that nurses (and other professionals) are perfectly capable of bullying (or “eating their own young”) even without MDs setting a negative example. The bullying that goes on within nursing (and among different parts of the nursing profession, broadly understood, including between RNs, NPs, LPNs, etc.) is just as important as the bulling that goes on between MDs and RNs.

The hardest questions I’ve ever been asked by med students and nursing students have to do with bullying, and with the difficulties inherent in being at the bottom of their respective professional hierarchies. Students understandably find it difficult — and a source of moral distress — to be not only subject to bullying, but to sometimes be involved in courses of action that they see as unethical and yet powerless to do anything about it. It’s hard to know what to tell them, because sometimes there really is very little they can do. But one thing they can do, I tell them, is to consider, starting right now, how they think they should treat those beneath them in the hierarchy, once they inevitably move up it, and how they are going to make sure they don’t fall into those all-too-common toxic behaviours.

(Notice that a story has been in the news recently about how poorly most US college students do at acquiring critical thinking skills during their post-secondary years. See: Study: Students slog through college, but don’t gain much in terms of critical thinking skills.)

One of the absolutely fundamental skills of critical thinking is argument analysis, or the interpretation of argument structure. And the fundamental elements of argument structure are argument premises and conclusions.

In everyday language, the word “argument” refers to a heated debate. When people are “having an argument,” they’re disagreeing vigorously with each other. But the word “argument,” in the context of critical thinking, refers to a series of statements, in which some of those statements (called “premises”) are offereds as reasons to believe another of the statements (called the “conclusion.”)

Understanding the way an argument is put together — its structure — is a very good step towards understanding its strengths and weaknesses. Knowing, for example, that a given argument has 3 separate premises rather than just 1, is fundamental to looking for its weaknesses: the more premises it has, for example, the more possible points of criticism. But even more fundamental is the fact that we gain a better appreciation of someone’s point if we can get a better perspective on the shape of their argument.

Look, for example, at this argument:

Nurses go through a rigorous licensing process. And nurses proclaim their dedication to putting the good of their patients before their own good. So, nurses should be respected as professionals.

We can represent this argument graphically, by means of a diagram, as follows:

The arrows in this diagram represent the author’s intended logical “flow” — they can be read roughly as representing the word “so” or “therefore.” This argument has 2 premises, each of which gives at least some support to the conclusion. (The fact that there are 2 arrows indicates that there are 2 separate chains of logic here; each premise gives some reason to believe the conclusion.) At this stage all we are doing is sketching the shape of the argument; we are not yet engaging in a critique. But from a critical perspective, this means that if you find fault with one of the premises, the conclusion is still supported — at least to some extent — by the other.

Next, compare that one to this argument:

Nurses around here are unionized. No unionized group can really be a profession. So, nursing (here) isn’t a true profession.

That argument can be diagrammed as follows:

This argument also has 2 premises. But notice that (as implied by the line joining them, and the single arrow flowing from that line to the argument’s conclusion) these 2 premises are working together. They need each other in order to lend support to the argument’s conclusion. This means that a convincing criticism of either one of those premises robs the argument of all of its force. That’s not to say that the conclusion is false, even if its premises fail; it’s just to say that this argument can’t support the conclusion, if even one of its premises is in doubt.

Now, those are very very simple arguments, and the analysis suggested here is not exactly profound. But the simple process of sketching the shape of an argument — your own or someone else’s — is useful in making clear just how much support the argument has, or doesn’t have, and where its weaknesses may be.

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The diagramming method used here is adapted from Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 2nd Canadian Edition, Oxford University Press, 2010.

But that’s not always the case.

See this story, from CNBC: Idaho board: No action in Walgreens complaint

The Idaho Board of Pharmacy says it has no basis to start proceedings against Walgreen Co. in a complaint that alleged one of the drug store chain’s pharmacists in Nampa improperly refused to fill a prescription.

A nurse practitioner from Planned Parenthood of the Great Northwest contended the pharmacist abused the state’s 2010 conscience law in November after balking at filling a prescription for a drug that helps control bleeding after childbirth or abortions….

This I think is a little-discussed aspect of “conscience clauses” or “conscience laws”: they can be a focal point for disagreement between members of different professions. Also, while conscience clauses may sometimes help nurses avoid participation in procedures that go against deeply-held values, in other cases such clauses are going to frustrate nurses’ attempts to help patients obtain the services of other health professionals.