Transforming Care: A Christian Vision of Nursing Practice (19 page)

These are just two of the central moral concerns that structure the
nurse's individual life. There are so many other concerns that we cannot
discuss all of them here, though many will certainly arise in later discussions of particular aspects of nursing. But the general approach that this
section offers - that of recognizing the value of the principle, while also
recognizing when it can lead to problems - is one that is valuable in all aspects of personal reflections on moral character.

It is sometimes tempting to assume that institutional morality is nothing
more than personal morality writ large, that all one really is responsible for
is to make sure that one's personal values are enshrined in the institution
of which one is a part. But things are never this simple, unfortunately. First
of all, values that can be held at the personal level without serious conflict
become far more difficult to balance at the institutional level. As an individual, for example, I have no difficulty recognizing the importance of the
principle that I should limit my actions as a nurse to those areas in which I
have knowledge. If I try to claim expertise in areas that I don't know about,
I am acting in a clearly immoral (and dangerous) way. At the purely personal level this is a fairly easy assessment to make.

Unfortunately, I may find that the institution of which I am a part
does not respect my own understanding of my limits. The practice of
"pulling nurses" has always been widespread in various hospital settings,
and it is becoming more problematic as nurses require increasingly spe cialized education to function in certain units. "Pulling" means that a
nurse who works in Labor and Delivery and knows himself to be competent in that setting may find that his unit is overstaffed so that he is sent to
a Pediatric Intensive Care Unit. He may not have the necessary expertise to
function properly in that context, but what is he to do? If he agrees to serve
in the PICU, he puts his clients at risk, and himself as well; but if he does
not agree, he may endanger clients by leaving the PICU understaffed and
may even lose his job. This is not an issue that can be resolved by careful
ethical reflection and individual fortitude because it is an issue that is generated by the institution of which one is a part.

Further, the rankings of values may change as we move from the level
of personal values to the level of institutional values. When I am concerned about my own responsibilities and relationships, my moral reasoning will be different than in cases where I am concerned about how an institution should be structured and how the various members of that
institution will be required or expected to contribute. It makes sense, for
example, to hold myself responsible to place the needs of my children high
on my list of priorities, but I can't expect a health care institution to do the
same.

Having noted these difficulties, we can also note that, from a Christian
perspective, the institutions designed to meet health care needs are fundamentally morally good. The fact that so many hospitals in the United
States are still named after their religious founding organizations (Jewish
Hospital, St. John's Health Care System, Methodist General) reflects the
fact that religious groups have seen providing systems of health care as a
central part of their mission, and they were absolutely correct in that perception. As Christians, we are called to participate in healing ministries.
Thus, just as we noted in the case of the nurse's personal vocation, so in the
case of institutions we are dealing with institutions that have a morally
good purpose (though this claim becomes more complex and problematic
in the instance of for-profit hospitals).

But, as is the case with individuals, institutions do not always live up to
appropriate standards. Because of the enormous amounts of money that
flow through the health care system, the system has vast potential for exploitation and abuse. And because of the power health care institutions
wield, they can also be used to control or oppress individuals. In both of
these cases the individuals who work within the system are faced with a
difficult problem. If they stay in the system and try to change it, they may become complicit with its problems. If they leave, they cannot change anything, and so they permit the problems to continue unabated.

There is no easy answer to problems of this sort, but it should be noted
that institutional problems generally require institutional answers. One cannot address issues of inadequate staffing as an individual. But nurse administrators, with the weight of their staff nurses behind them, can challenge unacceptable practices and call for change. Action as a member of a group takes
different skills and poses different challenges than action as an individual, but
such collective action is an important part of functioning as a professional
body. In the case of the nurse pulled from Labor and Delivery, for example,
individual action is more likely to get him fired than to solve the problem. But
collective action by all the nurses in a hospital system may be able to make
some adjustments to protect both clients and nurses in such a case, either by
limiting the units between which nurses can be pulled or by requiring some
sort of mentorship for nurses brought into areas outside their expertise.

Likewise, the case with which we began this chapter is a case of institutional ethics, not a case of purely personal responsibility. Tanisha is right to
note that when a hospital system has a contract with a group of nurses, it is
fundamentally unjust for that contract to be discarded simply because the
administration finds it inconvenient. Because this is an institutional issue,
however, it requires an institutional response, not a personal one. Annette
is rightly concerned that the clients not be the ones who suffer while it is
being resolved, but it needs to be resolved fairly so that, in the long run, client care can be provided adequately and competently.

Institutions do not exist in a vacuum, however. The hospital system that is
causing problems for Sheryl, Tanisha, and Annette is itself facing increasing pressure from managed care systems and insurance providers to cut
costs. This means that we need to consider a third level of ethical analysis,
that of social structures.

When we move to social structures, we are not dealing with particular
institutions any longer. Instead, we are dealing with the social organization
of health care - the insurance providers and political forces that determine
how health care will be structured. The level of social structures is the most
abstract and the most recalcitrant to change. At the same time, however, it is an area of human life in which changes have the greatest effect. I can be as
concerned as I like about whether or not the poor have access to basic
health care, and I can (at the personal level) perhaps make it possible for
some individuals to get health care by paying for it myself. But if I can work
with others in the community to set up a system of neighborhood clinics to
provide basic care I will have made it possible for far more people to gain
access to health care, and I may even enable the continuation of this care
beyond the span of my own lifetime. So it is crucial that we think clearly
and carefully about social structures and how they affect people's lives.

Nursing as a profession has become more vocal at this level in recent
years, though the advice of the American Nurses Association does not carry
the weight of an organization such as the American Medical Association.
This is an important aspect of nursing, though one that does not receive as
much attention as it perhaps should. Nurses, especially Christian nurses,
have the capacity to provide important insights into problems in health
care and solutions to recalcitrant dilemmas. But those insights will not be
heard unless nurses see themselves as having the responsibility to speak out
and to organize venues for bringing political and legal pressure to bear.

This is an issue that makes nurses uncomfortable, and sometimes
Christian nurses in particular think that they should not be involved in
policy-level decisions. As we heard Annette say at the beginning of the
chapter, some nurses think of themselves as subservient, not political activists, and some define their Christian identity in terms of obedience to
authority. But Christians are never called to offer unthinking obedience to
political authority. When authorities act in ways that are not acceptable,
we are not justified in sitting passively on the sidelines. Sometimes we are
called to mitigate harm; sometimes we are called to speak prophetically to
challenge the authorities. Both care and justice are central aspects of our
concern here. Unless we care about clients and their needs, we will not see
the ways in which the system of health care fails them. And if we cannot articulate the ways in which rights are being infringed or power is being used
unjustly, we cannot challenge the system to change.

We have a basic framework for ethical reflection in hand at this point, one
that contains the two principles of care and justice and the three levels of analysis: personal, institutional, and social. Is this all we need, and what
can we expect from such a picture? Any answer to this question has to
adopt a sort of good news/bad news structure. The bad news is that no one
can produce a neat ethical system that will always produce the right answer
for every ethical problem. But the good news is much the same. As
H. Richard Niebuhr put it, we are "responsible selves," mature and loving
responders to the God who creates, redeems, and sustains us (Niebuhr
1963, 52). This means that there can be no substitute for careful critical
thought about difficult ethical issues, and it means that we cannot always
get ethics right simply by finding the proper ethical authority and obeying
it, or him, or her. So what we are aiming for here is not an easy answer, or
even an absolute right or good action. Instead, we seek a "fitting" response,
one that "fits" with who we are, what we are able to understand of our circumstances, and what flows from and is guided by our central values.

As moral agents, we can never expect to be able to hand over our conscience to another. To be a moral agent is to be responsible for making
judgments and choosing to act under conditions where it is not always
clear what the right thing is to do. As Christians we are sometimes tempted
to pretend that this is not our situation. Christians are often encouraged to
set aside the need for moral reflection and instead to try to set up a list of
rules, which, if followed, will result in righteousness. Unfortunately, we see
in the New Testament that this leads to legalism, not righteousness.
Christ's constant call to see the intent of legal rules and to act to support
that intent, rather than adhering to the rule even when that adherence is
destructive of the rule's very purpose, is instructive here. When Jesus addressed the issue of Sabbath laws, his constant refrain, whether when healing a man with a crippled arm or discussing his disciples' eating grain
picked from a field, was that the Sabbath laws were created to enrich and
protect human life. Humans are not made to obey Sabbath laws, he reminds us; rather, the Sabbath laws are to function for the preservation and
enrichment of human life.

This is true of all moral rules: they exist to enrich and protect human
life. Whenever we elevate a particular rule above any concern for how it affects people we begin to act in ways that are both unjust and contrary to
the example Christ sets for us. And this is a real danger for Christians, who
often are concerned about righteousness and can, by that very concern, become vulnerable to a particular sort of unrighteousness based on legalism.
An example from the past is easy to find. When Christians defended slav ery on the basis of scriptural codes of behavior for slaves, they used legalism to avoid seeing the destructiveness of the practice of slavery in people's
lives. But we can also sometimes see this same tendency today. When some
Christians are concerned with sniffing out the least trace of anything that
can be called "idolatry" (no Halloween costumes! no Christmas trees! no
Harry Potter!) while remaining entirely blind to the ways in which they
bring dishonor to the name of God by portraying the Christian life as one
of joyless, cramped legalism, we see a contemporary version of that same
tendency. Moral rules must always be applied in the context of loving concern for particular individuals. When they are applied for the sake of the
rule itself and nothing else, they can become evil.

But as we noted at the beginning of this chapter, the same is true of the
opposite error. We cannot dispense with rules, principles, and laws and
"just love everybody." Active moral engagement with the world requires us
to make firm judgments about right and wrong and to be clear about what
is and what is not morally acceptable. Concern for particular individuals
should never blind us to the many ways in which individuals may choose
to do things that are simply wrong or the many ways in which we ourselves
may be tempted to choose easy nonjudgmentalism rather than the difficult
choice of confronting evil.

Nurses do not face an easy task in trying to discern the proper moral
response to the many ethical issues that confront them in their profession.
We live in a complicated world, and one in which the voices of the weak
have a hard time being heard. Nurses have the responsibility, as part of
their vocation, to speak for the importance of health care for all and to
work to make that a reality. We may never see that goal accomplished in its
fullness, but in striving for it we are working with the God who heals the
sick and lifts up the fallen, and that is a worthwhile way to spend one's life.
The kingdom of God is in our midst now but has not yet fully come. And
so we find ourselves looking for its presence, anticipating its fullness, and
working toward its ends.