Transforming Care: A Christian Vision of Nursing Practice (18 page)

This leads us, in fact, to the second big ethical principle we need to keep in
mind as we think about nursing and ethics, that of justice. Care is central
and important, but if we focus only on care we are likely to miss important
features of many situations. People have needs and vulnerabilities that
need to be met. Care encourages us to see these needs and vulnerabilities
and to respond to them. But other questions need to be asked, such as how
these needs and vulnerabilities arose, and why, and sometimes these questions shift the way we think about a caring response. We do need to be attentive to others' needs and vulnerabilities, but when we begin to ask ourselves why they are vulnerable or needy in those particular ways, we
sometimes begin to see that there are issues of power and the abuse of
power that contribute to the brokenness of our world.

We began this chapter with three nurses talking about their contractual relationship with the hospital administration. They noted that it is
unjust to ignore contractual issues. But the injustice of the situation may
go deeper than this. Nursing as a profession has had a long and complicated relationship with hospital administrations, physician groups, and
(more recently) managed care administrations precisely because these
groups have wanted to define nursing as a subordinate profession (Group
and Roberts 2oo1; Baer and Gordon 1996). When we focus on issues of this
sort we face a different set of issues than those we've talked about in terms of care. These are not questions about whether or not there are needs and
vulnerabilities; rather, these are questions about how we should arrange to
distribute benefits and burdens in society, how we should organize our
communal life fairly, and how various distributions of power create or
maintain vulnerabilities. In a word, these are issues of justice.

Justice and care converge at some point, since it is not possible to care
adequately under conditions of grave injustice, nor can a situation be
called just in which people are not able to develop and maintain relationships of care for each other. But convergence is not identity - we need
both concepts for an adequate account of how human ethical life should
be structured. And we see in Scripture that both are invoked when God's
character is described. God is a God of love and mercy, surely, but God is
also a God of justice, described as being as dangerous as a mother bear
whose cubs have been threatened and as being full of wrath at those who
perpetrate evil. And in Jesus we again see this aspect of God's nature. Jesus
did not shy away from calling people to repent. His ministry was one of
healing, certainly, but it also included driving the money lenders out of the
temple, calling people to an awareness of the holiness of God and to an
awareness of the many ways in which we fail to worship God or respect his
image in the other people we see around us. In his Confessions Augustine
notes how blind we can be to the true value of things. He offers the example of a lawyer arguing in court, noting that the lawyer is likely to be centrally concerned with whether or not he argues well and effectively, all the
while ignoring the fact that a person's life is at stake. The death of a person
made in the image of God is far more important than whether one's rhetoric is carefully polished, and yet we are unconcerned with the very image
of God who is in front of us, Augustine says, while we focus on whether or
not we put our words in the right order (Augustine 1998, 21).

Justice is centrally a matter of equity and fairness. We very often speak
in the language of rights when we are concerned about justice matters because rights allow us to recognize inequities in treatment. The basic human rights - rights to life, rights to freedom of religion and conscience,
rights to be free from unwarranted arrest or confinement - are all designed to prevent the grossest infringements against fairness. So when we
turn to issues of justice, we find ourselves concerned with questions about
how practices are organized, whether or not social structures respect the
rights of the people affected by them, and how fairly benefits and burdens
are distributed by those structures.

Some aspects of justice issues are more easily seen in the health care
context than others. The last thirty years have seen a careful articulation of
the notion of patients' rights, autonomy, informed consent, and the like.
All of these are justice issues because they all involve attempts to build into
the structure of health care delivery a basic respect for the rights of clients.
But other issues are often not as central to considerations of justice in
health care.

Take, for example, the issue of nurse practitioners and physician control of health care. Physicians' groups such as the AMA (American Medical
Association) have regularly lobbied hard against nurse practitioners providing primary health care, even though there are insufficient primarycare physicians to provide such care, and even though several studies have
shown that the care provided by nurse practitioners is equivalent to or
better than that offered by physicians (Group and Roberts 2001, 418). This
is clearly not a struggle about the provision of adequate care but a struggle
over privilege and power. Those who have power rarely give it up without a
fight, and those who want to change power relationships need to expect
such a fight.

It is high time to take our
bearings from the orientation toward a justice that
fits good news to the poor.

ALLEN VERHEY

So this brings us to Sheryl's question at the beginning of the chapter.
Can Christian nurses be involved in fights for justice, or should they instead think of their role as one of exemplifying Christ-like, sacrificial service? This is a pertinent question for nurses in particular because nursing,
in its historical development, has been defined in terms of care rather than
justice (Nelson 2001, 51). But Christianity is wrongly understood if it is
made to serve the cause of injustice. We have historical examples of this
misuse of Christianity - apartheid in
South Africa, American slavery and racism, violent opposition to women's rights,
and the Crusades - and they still bring
dishonor to the church. Christians do
need to strive for sacrificial service, but
that service needs to be directed to God,
not to the powerful of this earth. Jesus'
own sacrifice was on behalf of broken and
vulnerable humanity. He always seemed
to prefer the poor, the outcast, the marginalized and powerless.

It is appropriate for Christian nurses to fight for justice, to speak up
when human rights are trampled on, and to call those in power to ac countability. Scripture is full of prophetic voices who remind those in
power that they are responsible to God for their decisions, and when we
are given the opportunity to work for justice we should not shrink back
out of a misplaced worry about lack of humility. Humility, properly speaking, is exemplified when we do not consider ourselves too good to serve
the weak, not when we are too scared to resist the injustice of the powerful.

Care and justice are both central to any understanding of the structure
of ethical issues. But care and justice function differently at different levels
of moral analysis. Care can involve empathetic understanding of another
when we are in a personal relationship with her or him; but when we are
thinking about the structure of health care delivery, empathetic understanding is less important than a clear grasp of how lack of access to primary care generates over-use of acute care facilities. So in the next section
we add another set of parameters to our framework: the parameters of different levels of analysis.

Ethical analysis and action shift as we consider different levels of social organization. For our purposes here we will divide ethical analysis into three
levels, though in our everyday experience these levels are always interpenetrating. The first is the level of personal morality. As an individual, what
do I believe, what should I be held responsible for, and what sorts of relationships are mandatory, acceptable, or unacceptable for me? The second
level is that of institutional morality. This level looks at how the nurse fits
into the institution of which she or he is a part. Finally, we have the level of
nursing as a practice and the social structures of which it is a part. It is important to separate these three levels of ethical analysis, in part because the
moral responsibilities of individuals differ at different levels. At the level of
personal ethical decision making, I need to make sure that my own beliefs,
responses, actions, and relationships are in line with the set of values I hold
and the values I see portrayed in Scripture. These responsibilities fall
squarely on me, and I cannot evade them by pointing to choices others
make. But at the level of institutional analysis, we are not focused so much
on individual responsibility as on corporate responsibility; there will be a
need for cooperative action and consensus building in addition to the individual decision making that goes on at the personal level. Of course, in practice we do not leave our personal responsibility behind, but in the
analysis of institutional morality our focus is elsewhere.

Finally, at the level of social structures we are focused to an even
greater extent on the need for collective action. When we think about the
place of nursing as a practice in the contemporary Western world, our
analysis needs to go far beyond the question of what moral values an individual should try to live out. We need instead to think about what sort of a
society we are and what sort of society we ought to be. As Christians, we
are convinced that there will always be a gap between these two, until
God's action renews creation, which means that there will always be a need
for critical thought and collective action to work toward rectifying the injustices and destructive aspects of the institutional structures.

Are there central features of the individual Christian's moral life that
should be structured in terms of particular values? And how can we think
about living out these values in our relationships and careers? Clearly
Christians are called to a life that embodies the sorts of concerns God portrays to us in Scripture. We are called to act in ways that model God's care
for us to a world in dire need of care and love. We are also called to act in
ways that reflect the holiness and justice of God and that demonstrate a
concern for justice, for a full recognition of the image of God in all people.
And (though we haven't made this an ethical principle) we are called to
live joyously, celebrating the gift of life and the goodness of creation in the
company of God and other people. This gives us a starting point for thinking about personal ethics and how we should think about our lives in the
context of nursing as a practice and as a vocation.

One of the first things to note is that nursing is an inherently ethical
and dignified vocation, as was noted earlier in our discussion of the nature
of nursing as a practice and of health as the focus of nursing. To be a nurse
is to choose to have, as a part of one's identity, a central focus on healing
and the maintenance of health and appropriate care for those whose
health is failing. This is a fundamentally moral goal and one to which
Christians are called to contribute. So nursing is an honorable practice,
one that can legitimately be the vocation to which a Christian is called.
This is not true of all careers. There are some "careers" in our society that no Christian should participate in (slum lords, pornographers, prostitution) and others that are structured in such a way that it is difficult to engage in them in any honorable way (certain types of advertising, businesses that deliberately subvert moral concerns in the interest of profit).
While we respect the many callings Christians can have as they seek to glorify God and serve others, we are also called to discernment in terms of
which careers can be legitimate places for us to live out those vocations. It
is thus important to note the essential moral core of nursing.

And because nursing is a fundamentally good calling, and the nurse's
job such an important one, an essential part of the good nurse's life involves self-care. That is, it is appropriate, even mandatory for a nurse to
care for herself or himself in ways that allow for a full and satisfying human life and that prevent the burnout that is appearing among nurses at
an alarming rate (Selles 2002). This self-care should not just be a matter of
physical care, though obviously that is important; rather, in keeping with
nursing's holistic perspective, it needs to be care for all the dimensions of
the self: physical, emotional, spiritual, and psychological.

Beyond this, the Christian nurse is called to live out the two values of
care and justice and thus to allow God to shine through her or his life to
the world. In terms of basic practice, then, the Christian nurse has the responsibility to meet the requirements of competency in practice and efficiency in action, since both of these are central ways in which one's actions
affect others. Without competency, the nurse runs the risk of harming clients. Without efficiency, the nurse runs the risk of creating unfair burdens
on others. Both of these responsibilities are central aspects of the nurse's
internalized education, and both are legitimate ethical concerns. Both, in
fact, are part of the notion of stewardship, of making good use of the resources and gifts God provides for use.

Before leaving them, however, it is worth thinking about whether
these responsibilities might also become, in certain cases, legalistic stumbling blocks. Rules and laws, remember, are good things, but never ends
in themselves. Without giving them up, we need to recognize that applying them unthinkingly may be problematic. The first principle can sometimes get in the way of asking for needed help or admitting that one is
overwhelmed with responsibility. Competency is a good thing - an essential thing - but we should never let our goal of competency make it
impossible to ask for help or guidance. The second principle, efficiency,
can sometimes function to make the nurse willing to do too much. As hospitals increasingly try to cut costs by making cuts in nursing staffing,
the internalized value of efficiency may make it difficult for nurses to recognize when too much is being demanded of them. Or, as some nurses
discover, the demands of ever-increasing efficiency in the context of managed care lead to nurses functioning like machines, performing mechanical functions on the bodies who pass under their care. Seeing a client as
an individual, worthwhile person becomes impossible in such a context,
and one of the central internal goods of nursing practice is then lost (Baer
and Gordon 1996, 228.) To the extent that the nurses blame themselves for
any jobs left undone they will be unable to see that perhaps it is the structure of the job itself that is placing demands on them that simply cannot
be met.