Beginning to Think About Ethical Issues in Critical Care

Welcome to a reimagined American Journal of Critical Care (AJCC) column on ethics and critical care! My goal for this column is to give voice to the ethical concerns of critical care nursing staff and unit administrators and encourage readers to think and talk carefully about the ethical issues they encounter. The multitude and profundity of the ethical issues that nurses face appear to be one of the causes of many nurses’ departure from critical care. Many of us know at least one colleague who has left critical care because of such issues. So, I am hoping that you will help with this column by scanning the QR code in the footnote (or emailing [email protected] with Ethics in the subject line) and sharing some of the ethical concerns you find most troublesome in critical care.From my point of view, it is a great honor to be writing a column for this prestigious journal! I have long looked for a place to seriously consider some of the many ethical concerns that occur for staff nurses. In this column, I hope to be able to give a voice to some of these issues as they are raised by you the readers and your colleagues. In today’s column, I plan to do 3 things: (1) introduce myself, (2) provide a brief introduction to how I generally think about ethical and human issues, and (3) ask for your input to help me see both what are some of the ethical issues you are encountering and what are your ideas about how we might approach them.My education is in both nursing and philosophy, and I spent many of my 30 years of nursing practice in critical care. I began in a burn center in San Diego and then practiced in various medical and surgical intensive care units (ICUs) as well as in perianesthesia nursing in other parts of the United States. More recently, I retired as emerita professor of philosophy after teaching philosophy at a liberal arts university in Kansas City, Missouri. I also served as the chair of the International Philosophy of Nursing Society. Thus, I have taught and written for many years about some of the philosophical and ethical issues in contemporary nursing. Currently I keep my hand in health care by volunteering in the operating room waiting area at a local teaching hospital.It would be helpful to share something of how I think about philosophical and ethical issues as I encounter them. Any time someone raises an ethical concern, they are expressing a concern about what is good or right for some particular person or group. I like to use the term “human person” to be clear that I’m talking about us, you and me, and not about higher-level primates or other animals who also may have traits that suggest that they have “personalities.” There certainly are ethical issues for these animals, but that is beyond the scope of our inquiry here. To speak about what is “good and or right” implies that we can know something about both the good and the right as well as something about what it means to be a “human person.” Of course, not all people believe that we can know any of these things. However, if we cannot identify some things about what it means to be a human person and about the good or the right, we have nowhere to begin. Ethics would then simply be a word with no meaning at all. What we are trying to do will not be easy. However, when committed thoughtful people put their heads together to examine ethical issues, they can come to what I think of as nuggets of truth. These nuggets of truth can serve as a guide to light the way to look at individual instances that critical care nurses experience.In order to think about what is good for something, we must first know at least a bit about the nature of that “thing.” So, if you are planning to grow tomatoes, you read up on how to best raise them. Here, I am following Aristotle, who tells us that to “know” something we must examine its actions and reactions.1 That, of course, is the basic “scientific method” followed today by all reputable scientists. For example, tomatoes grow best in good soil and flourish in sunlight with the right amount of nutrients in their soil and enough water. We recognize a “good” tomato by its size and shape, color, flavor, and texture.To understand what it means to be a human person, we must look at how we act and react, not simply at the individual level but generally, across cultures and over time. What are the actions and reactions that are generally found in the people we encounter? Here I am following the theory in an article published in Nursing Research.2 First and perhaps most important, we are radically relational. We are related to our parents whether we know them or not, we live in society, whether we want to or not, and our bodies act and react to various cultural, chemical, and environmental conditions in certain ways. Part of being relational is that we are social beings. We are born into a society, and that society teaches us, gives us language, mores, and values. When a “loner” shuns society, it is precisely to try to avoid these influences; however, that person remains related to that society simply in trying to avoid it. For this reason, in health care, we no longer keep family and friends at a distance but bring them into the conversation where appropriate.We are embodied. It is often that physical, material body of the ICU patient that first presents to us as nurses. As embodied, we are determined to be what we are in important ways, though not entirely, by our cellular chemistry, physics, biology, DNA, as well as our physical and environmental history. Modern medicine, tests, scans, and the like give us important but also incomplete information about the embodied nature of our patients.A small digression is helpful here. I speak about the people who are the recipients of nursing care as “patients” rather than as “clients.” A client relationship implies that there is reciprocity, an equality of knowledge and/or power, and an ability to redress problems through financial or legal means if necessary. However, people come to the health care provider not as consumers, but rather seeking help with their own person. There is a radical inequality of knowledge and power that it is important to recognize and address. Even patients who are physicians or nurses present to health care providers in this unequal position. Any damage done in the health care setting often cannot be corrected and cannot even be addressed in anything other than human terms, even in the face of legal action.We are knowers. We seek to understand ourselves and the world around us. That begins with, but certainly does not end with, perception. Think of the infant exploring the world with their fingers, toes, mouth, eyes, ears, every part of their body. We are capable of at least 2 kinds of knowledge. First, subjective knowledge is what we know about ourselves. This knowledge cannot be directly known by other people. We must share this knowledge through our verbal language and through body language. This sharing would include the hopes and fears as well as the internal perceptions of our selves or of our critically ill patients. Second, we can have objective knowledge. This means that we have knowledge that is available to be verified directly by other people, such as the temperature or wind direction, the phase of the moon, or the physical signs and symptoms that critical care patients present. These many different ways of gathering information, all put together, allow us to know things that are not immediately obvious to others. Mothers know their children, husbands or wives, their spouses. We, then, listen to this knowledge and take all this information into account as we work to achieve the best care for our ICU patients.We are purposive. We always act in order to achieve some purpose or goal, something that we perceive to be good for ourselves. Sometimes, of course, we are mistaken. We may be confused or not aware of what is good or harmful. But whatever we do, we are always acting to maintain or achieve what we believe or feel is good for us. This purposiveness may lead our patients in critical care to pursue actions that we believe are against their own good, which raises the problem of when we must intervene and when we must sit back and allow their free choice.We are unique. This is a foundational principle of our very being. Each of us presents with a particular DNA, with physical and emotional characteristics, even if we are an identical twin. We are born into a particular and unrepeatable time and place in the world. Because of this uniqueness of being, we act and react in our own unique way. Our physical place in the world, our culture, our physical, mental, and emotional capacities and incapacities all coincide to make us unrepeatable individuals. This is why it is crucial to provide equally good critical care to the most vulnerable and to the most important people.We live ourselves. Husserl calls this “lived experience.”3 Because we are unique individuals in an unrepeatable time and place, our experience of that world is also totally unique, even while it may be similar to the experience of others near us. We experience our bodily chemistry, our stomachache or our low blood sugar, and we understand ourselves in sometimes explicit and clear ways and sometimes in simply confused ways of being. Therefore, we nurses try to listen carefully to the ICU patient telling us what is happening to them. Often we also listen by carefully observing their nonverbal actions.Finally, we are transcendent beings. Many of our actions, probably many more than we realize, transcend the limits of time and space simply as we share our love, compassion, knowledge, art, music, and the like. Think of the Pythagorean theorem. Pythagoras identified it several thousand years ago and it has remained unchanged over all this time. Or Beethoven’s Fifth Symphony. Or grandmother’s recipe for cornbread. It is because of this that we both learn from and are able to demonstrate aspects of our humanity in our caring interactions with ICU patients.Critical care nurses may be educated in one part of the world and then travel to pretty much any other place and function as an ICU nurse. The reason this works is because the persons who are nurses and those who are patients are pretty much the same, place to place and time to time, and because nursing has at its core similar practices and beliefs across cultures and across time, even as it becomes more complex and nuanced.When we think about ethical problems, then, we are thinking about what is good for the people who are involved. These 7 aspects of our human nature (italicized above) provide us with a beginning point from which to examine ethical concerns in critical care. What aspect or aspects of the person are at issue in the problem at hand? Because health care is an interaction, and usually there are several people involved, it will be necessary to think about the problem from the vantage points of all those involved.Thus, I encourage you to think about the problems you are seeing in your own ICU area, imagine the issue from as many points of view as possible, and send us your ideas. Please be assured that no identifying information will be published. What do you think might be helpful in thinking about the problem or perhaps in solving it? How do your colleagues see the ethical problem and possible solutions? We are looking forward to hearing what you have on your minds.