Until the 19th century doctors relied on intuition, experi-ence and creativity, they were not considered practising healers who use scientific activity, concrete theoretical knowledge. In their work, an outstanding role was attribut-ed to the importance of establishing interpersonal relations with patients, resulting from which behavioural culture was practised on a very high level. Later, with technical and sci-entific development, professionalism got prominence, and behavioural and relationship factors were pushed to the background. This process started later in the field of nursing.
In biomedical healtcare, relational and behavioural phenom-ena could not compete with the development and achieve-ments of science, due to which healthcare provision became impersonal.
Nowadays, in holistic bio-psycho-social healthcare, con-necting relations are appreciated. These well-being factors ap-pear as important factors in developing, running and therapy of illnesses. The doctors’ and nurses’ task is not only cure and attention to the disease but also to the sick person. However, this can only result from interpersonal relations, in which doc-tors and nurses are also active participants with the whole of their personality, behaviour and emotions.
Healthcare has become multi-participant. The nurse, a new participant appeared in the traditional doctor-patient relation and later after medicalization and with advanced hospital at-tendance other members of a team (e.g. physiotherapist, di-etician, operating room staff ) joined in medical attendance.
The patient, depending on his condition, appears in different fields of healthcare provision, thus several teams take part in his care, and this needs co-ordination.
Within this complex healthcare context, traditional nurs-ing roles have gained importance. Nursnurs-ing education has changed, expanded, but also has become specialized result-ing in a hierarchical ratresult-ing of the profession on the basis of acquired knowledge, abilities and skills. According to the acquired qualification, different responsibility relations have emerged. Responsibility and in this way decisional autonomy have increased concerning nursing interventions, the nursing process (survey, planning, implementation, evaluation).
The essence of ethical nursing behaviour is responsibility, which is a complex concept including responsibility for their own work, for the work in the attending team, as well as de-cisional responsibility and representation of the patients, and actionable conduct.
1. Ethical independence (autonomy) includes the dimensions of personality, self-esteem and ethical reliability. Apart from carrying out activities of the nursing profession, indepen-dence also appears in observing the patients’ autonomy. The responsibilities assumed in the nursing activities may be :
• personal responsibility the prerequisite of which is the maturity of the nurse to perform the task, as well as the voluntarily assumed behaviour, work;
• competency which is determined by its adequacy to abilities;
• professional responsibility which means adequacy to professional guidelines;
• legal responsibility which requires adequacy to civil, la-bour and criminal law, and
• ethical responsibility which influences the nurse’s res-ponsibility by means of written (code of ethics) and un-written rules (conscience).
Autonomy is in fact nothing but respect for the other per-son’s (the patient’s) thinking, that is, acceptance of the fact that the other person (the patient) can make decisions according to the frame of references available to him. Autonomy and respect for the individual means ensuring the individual’s self-determination even in a case when it is dangerous for him.
It is very difficult to provide this in emergency and intensive care units, in such cases when the patient temporarily loses his autonomy, his responsibility to make decisions.
Ethical dilemmas are brought on by taking over the re-sponsibility or the possibility of taking over the responsi-bility to make decisions in the case of sick children, coma-tose patients, severely mentally disabled and psychiatric patients.
2. In professional terms, the nurse performs her work follow-ing the doctor’s instructions and in accordance with fessional standards. However, it is her ethical duty to pro-tect the patients’ right to self-determination, representing the patients’ rights.
3. As a consequence of her responsibility, the nurse can be held accountable because of her professional role, and ac-tionable conduct is possible in the case of ethical faults. Of course, if the nurse commits a professional fault according to her own ethical judgement, which endangers the pa-tient, she is accountable.
Examples
d
eciSion-
makingofchildrenThe most commonly accepted basic principle of bioethics is respect for and protection of the patient’s right to self-deter-mination. The patient’s self-determination covers all health-care interventions concerning him. Informed consent is nec-essary to interventions.
In the case of children, as they have no capacity accord-ing to the operative law, the legal representative exercises the child’s rights. Thus legally the parent can make all sorts of healthcare statements of rights on behalf of and in the inter-est of the child.
In the case of children, prominent ethical dillemas are the issues relating to the attendance to incurable children and al-leviation of pain. Children also have experiences of pain.
In recent years the definition of a worthy life has spread, which puts forward the importance of quality of life gained.
It is essentially the patient’s judgement of his own condi-tion and anticipated prospects. It is important to emphasize that the child’s best interest and opinion must be taken into account in accordance with his age. A worthy life can mean different concepts to different people. The best interest of the child – considered the best by the doctor – can con-siderably limit the parent’s right of determination in certain cases.
Traditionally, in the case of children, parents and doctors, nurses take part in making the decisions. That is why conflicts may occur between substitute decision-makers (parents and professional groups) in order to ensure the ‘best interest’ of the child. However, nowadays children’s cognitive develop-ment is taken into account and they are getting a more and more active role in the decisions concerning them.
Nurses are faced with a complex ethical challenge when protecting the diseased child’s interests. In intensive care units or paediatric oncology departments as places for the treatment of incurable, dying children, accentuated tasks are symptomatic treatment, joint decision-making, efficient com-munication between the patient and the family members, continuity of provision and support for the family.
224 Textbook of Nursing Science Chapter 8 Ethical Aspect of the Nursing Profession 225
e
thicaliSSueS oforganandtiSSue tranSPlantation With the very rapid technological development, the number of organ transplantations has increased, however, there are few donated organs to meet the increasing needs. This gener-ates continuous legal and ethical problems.In the course of ‘live donation’ (organ transplantation from a living donor), special circumspection is required with in-formed consent, the possible complications must particularly be included in the information given since the donor might even risk his life. Organ transplantation has to be voluntary, free from any influence, in the meantime it is very difficult to judge but also avoid the psychic pressure from the members of the family. In order to prevent abuse, it is important for or-gan donation to be free.
Nowadays there are two accepted forms of organ removal from dead bodies:
• In the system of ‘opting out’ the lack of refusal, that is the presumed consent makes it possible for organs to be removed at any time from the suitable body, except for the case when the individual disposed otherwise when still alive.
• In the system of ‘opting in’ the individual in his life makes a written statement (e.g. donor card) in which he deter-mines how his organs must be handled after his death.
In Belgium, just like in our country, ‘presumed consent’ was included in the law. According to the law, 98% of the Belgian population are potential donors, and healthcare providers are not obliged legally to inform the relatives about the donation.
However, the law is incompatible with bioethical basic prin-ciples, and with the individual’s right to free disposal about their body after death as well.
Transplantation of organs and tissue removed from cadav-ers (dead human bodies):
With respect to consent given to organ and tissue removal from a dead body, there are three systems in bioethics and legislation:
• The principle of positive consent means that such an intervention can only be performed if the individual sta-ted his agreement when still alive.
• According to the principle of consent from relatives, if the donor did not make a statement of refusal in his life, the relatives can decide about the removal of organs or tissue.
• On the basis of the principle of presumed consent, if the person did not make a statement in his life, the consent is presumed by the law, thus he can be considered a potential donor.
In the case of the underage this is not possible, therefore the legal representative is required to make a written agree-ment.
In the case of an underage donor, the law is the same else-where in the world: the parent, the guardian, the legal repre-sentative needs to give their consent to organ removal. This
raises a new ethical question: is it completely acceptable in ethical terms if a relative who is not related by blood to the underage child has to make the decision?
It is known that the issue of organ and tissue transplan-tation is not only about determination of the time of death, since here there are not only dead but also live donors, let alone the patient who receives the organ, who just like the donor has personality rights and dignity, and who also has to prepare for living with someone else’s kidney, liver, heart, pan-creas, bone marrow etc., similarly to those who decide to do-nate some organ for medical science for therapeutic purpose.
Furthermore, self-assessment, self-image, change in personal-ity – which do not remain intact during such an intervention – of the patient concerned in organ transplantation could be the subject of an ethical examination. However, it can happen that the patient refuses organ transplantation, but his deci-sion must be respected. This decideci-sion is not a decideci-sion against the dignity of life or idolizing the dignity of death.
P
SychologicalantecedentSandmoraleffectSoftranSPlantation
Some patients wait for a suitable organ for years. The tension and anxiety of waiting and preparation are usually not dealt with because they are swept by the reality of the performed transplantation. It is a severe psychic strain on the patient to accept the fact that someone’s death is necessary for him to be able to survive. It would be a natural emotional response to refuse, since if we only think of general morality, this fact is really unacceptable instinctively, and in many cases this is what happens. It would be important to go over this issue in a way that his sense of responsibility and guilt diminishes. He has to accept psychically and morally that this is the only way he can survive. However, these thoughts remain, are kindled later too since he lives with another man’s organ. In spite of the fact that many times the donor remains largely unknown in reality, he is partially outlined in the recipient personality’s conscious and unconscious imagination as a regular psychic phenomenon.
It is not enough to replace the old diseased organ with an-other one, the patient must accept the change mentally too.
Without parting and mourning there is no real space for the new organ. The patient has to accept the new organ as a pres-ent, and in this way integrate it into his own body. One is faced with new challenges in his after-transplantation life.
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Introduction
During the practice of their profession physicians, nurses and health care professionals continually come across patients and family members having suffered from loss. Concepts and theoretical and practical knowledge related to loss and be-reavement serve as a useful frame during nursing. While being in contact and collaboration with patients and their families this helps nurses to create an atmosphere in the given en-vironment where the people involved can have a chance of expressing their physical, spiritual and social pain. Supporting patients and their families, listening to and understanding them, respecting their value system, taking their convictions and wishes into consideration are all pillars of cardinal impor-tance in nursing. A relationship which is based on trust creates such a therapeutic atmosphere that facilitates processing loss and bereavement and strengthens the dignity of patients and their families and increases their self-respect. In the course of the care of mourning or dying patients and their families the understanding behaviour of nurses contributes to the philan-tropical overcoming of difficulties. These are of crucial impor-tance in hospice care. In palliative care it is increasingly seen that it is not sufficient to eliminate and reduce the patient’s symptoms but holistic, individualized care must be sought.
The hospice model should include the somatic, psychosocial and spiritual needs during the disease and in the period of mourning as well. Caring for dying patients and their families at such a level is a difficult task for everyone. The servant of Ivan Ilyich understood that in such cases, the dedicated pres-ence, positive reinforcement, compassion, and countless tiny gestures may mean comfort for the patient and the family.
These implications of nursing are recently described with the help of concepts such as the intellect, purpose, dignity, and spiritual or existential well-being.