Archive for the ‘critical thinking’ Category

The Globe & Mail recently ran an interesting piece called “Nurse, who should see the doctor first?”, which challenged readers to prioritize 4 hypothetical visitors to an ER. The question: who should be seen first by a doctor, and why?

The 4 patients (described in greater detail in the article) were…

A man complaining of chest pains and shortness of breath following a long airplane flight.
A young woman with a painful sprained ankle.
A middle-aged man with a headache, blurred vision and an inability to use his right arm.
A senior man who’d shot himself in the hand with a nail gun.

The follow-up piece, featuring the wisdom of an experienced ER nurse, is here: “What would a nurse do?”

Here’s the order recommended:

#1 The middle-aged man with a headache, blurred vision and an inability to use his right arm.
#2 The man complaining of chest pains and shortness of breath following a long airplane flight.
#3 The young woman with a painful sprained ankle.
#4 The senior who’d shot himself in the hand with a nail gun.

It would be easy — and useful — to add details to each patient’s story to make this into a good exercise for an ethics class.

Questions for disucussion:

    Should it matter if one of the patients is homeless?
    Should it matter if one of the patients is a “whiner”?
    Should it matter if one of the patients is a verbally abusive?
    Should it matter if the nail gun injury is the man’s “own ‘fault”?
    Should it matter if one of the patients is a local celebrity?
    Should it matter if the girl with the sprained ankle is the daughter of a major donor to the hospital?
    Should it matter if the patient is a “frequent flyer” (i.e., someone who visits the ER quite often, perhaps seeking attention)?

This is a great example of the close interconnection between nursing skills and ethical decision making.

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A recent book review in the Chronicle of Higher Education highlights the most recent work of neuroscientist, philosopher and author Patricia Churchland, who offers some interesting views on modern day morality, in her new book Braintrust: What Neuroscience Tells Us About Morality(Princeton University Press)

Here’s an excerpt from the Chronicle review of Churchland’s book: Rule Breaker: When it comes to morality, the philosopher Patricia Churchland refuses to stand on principle

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.

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This is the 2nd in a series of postings on the value of critical thinking in nursing ethics.

(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.

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.

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This is Part 1 in an series of postings we’ll be doing on the role of critical thinking in Nursing Ethics, here on the Nursing Ethics Blog.

Let’s start with a definition. Critical thinking can be defined as “the systematic evaluation or formulation of beliefs, or statements, by rational standards.”*

In terms of nursing ethics, that definition has several crucial elements.

The first has to do with the word “systematic.” Thinking critically about ethical standards in nursing is “systematic” in that it has to do with the application of distinct procedures and methods. At times, that might involve the use of very technical tools, such as the tools of formal logic, to assess the validity of arguments. In other cases, it will involve looking for well-known patterns of good or bad reasoning, including for example the many fallacies to which human reason is sometimes subject. In other cases, being systematic will simply mean looking carefully at the various parts of an argument (its premises and conclusions) and at how the argument is structured, in order better to assess its strengths and weaknesses. Thinking critically about nursing ethics means doing something more than having an opinion. It implies a careful, systematic approach.

Here’s an example. Imagine a fellow nurse, one administering a clinical trial, says to you, “If someone is my patient, then I owe that person a duty of care. Right? And according to the relevant regulations, I owe the participants in this clinical trial a duty of care, so they must therefore count as my patients!” That’s an ethically significant conclusion. But is the argument leading to it a good one?

At some level, that argument may sound plausible, and to many nurses, the conclusion will be an attractive one. But someone skilled in critical thinking might recognize that that argument has the following form:

If P, then Q.
Therefore, P.

Arguments of that form are pretty common (so common, in fact, that they’ve been given a technical name, “affirming the consequent”) and they are always, always faulty. The premises of an argument with that structure simply cannot support that conclusion. But good critical thinkers will also recognize that the failure of this argument doesn’t automatically spell doom for that argument’s conclusion: it just means that someone needs to try again.

The second implication of the definition of critical thinking offered above has to do with what it says about about “evaluation” and “formulation” of beliefs. This implies that critical thinking is to be applied to evaluating existing beliefs as well as to the process of building new ones. In terms of nursing ethics, then, critical thinking can be used in two ways. First, it can be used as part of reflective practice, as part of evaluating our own current beliefs about what constitutes ethical or unethical nursing practice. Second, it can be used in formulating new ethical standards, for example when a new code of ethics or is being devised.

The third implication has to do with the words “rational standards.” Those words imply that particular views about nursing ethics (or bioethics or professional ethics, more generally) ought to be judged by how well they are supported by good reasons. That is, a commitment to thinking critically about nursing ethics means only adopting points of view that you have good reasons to adopt, and committing to values you have good reasons to be committed to, rather than adhering to stale, unexamined beliefs or doing things a particular way “because that’s the way we’ve always done it.”

As this series progresses, we’ll look at different elements of critical thinking, and how some of the specific skills of critical thinking can be applied to thinking about nursing ethics.

*Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 2nd Canadian Edition, Oxford University Press, 2010.

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