This inevitably creates tension between the person’s autonomy (the right to make decisions about their healthcare) and utilitarianism. It becomes an issue of justice and goodness. Gilligan (1982) argues that women and men have different criteria to judge ‘moral goodness’. Men tend towards that the highest moral claim is justice (utilitarianism) based on the utilitarian ethic, whereas women tend towards the highest moral claim of caring and responsibility that is essentially respecting the person’s autonomy. Gilligan suggests that within a patriarchal culture, the masculine ethic is deemed a higher level of ethical development, that the needs of society as a whole is morally greater than the needs of the individuals within that society because of finite resources. The reader will appreciate the way this tension is played out in everyday life, reflected in the media, about the way decisions are made about healthcare – what is funded and what is not, as supported by NICE. As such, the person’s right to make decisions about their healthcare is constrained by resources available as determined by others with greater authority. Hence the practitioner will reflect on how utilitarianism affects the ability to give patient‐centred care due to finite resources. This, in turn, impacts on number of staff available, how priorities are made, how much time can be spent with one patient, what equipment is available and staff development. It behoves the practitioner to become political to assert necessary resources to create an environment where her vision can be realised. This is very difficult for the individual practitioner and requires community action or wider society action no longer tolerating poor care. The NHS is a constant political battleground. In the 2019 election, the Conservatives promised 50 000 more nurses and 23 billion pounds.
Confidentiality
Confidentiality, as enshrined with the data protection act (1998), aims to protect information about a patient being communicated to others without the patient’s permission. This potentially creates a dilemma for healthcare practitioners’ intent to care for relatives who are anxious for information that can easily lead to a breakdown of trust.
The Ethical Demand (Justice, Equality, and Cultural Safety)
Many writers have written about the nature of care and the demand that puts on carers to act for what is espoused as the ‘good’. Consider Logstrup’s (1997, p. 18) ethical demand:
By our very attitude to one another we help to shape one another’s world. By our attitude to the other person we help to determine the scope and the hue of his or her world; we make it large and small, bright or drab, rich or dull, threatening or secure. We help to shape his or her world, not by theories and views but by our very attitude to him or her. Herein lies the unarticulated and one might say anonymous demand that we take care of the life which trust has placed into our hands.
Clearly attitude, as noted previously, is a significant aspect being person‐centred. Negative attitudes lead to such phenomena as the ‘difficult patient’, the ‘interfering relative’ and racism. For example, issues surrounding racism continue to surface (Blackford 2003; Puzan 2003), perhaps more so at this time of writing in light of the ‘Black lives matter’ movement2 and the global response to George Floyd’s death by a policeman in the USA on 25 May 2020 demanding justice and equality. As Puzan (2003, p. 194) writes:
There is so much familiarity in talking about the alleged racial differences of non‐white people in public discourse and so little familiarity in talking about those racial properties attached to being white, that the concept of whiteness (or a recognition of racial formation) has little resonance within nursing (citing Jacobson 1998). While issues related to cultural difference are not ignored, they rarely include the difference specifically engendered by ‘whiteness’, which is structured to avoid and deflect interrogation or critical reflection.
Puzan’s words challenge all healthcare practitioners, health organisations, and health systems about the right attitude to hold towards all people irrespective of race to ensure cultural safety and health equity. A commonly used definition of cultural safety is that of Williams (1999, p. 213), who defines cultural safety as: an environment that is spiritually, socially, and emotionally safe, as well as physically safe for people; where there is no assault challenge or denial of their identity, of who they are and what they need.3 From a healthcare perspective, Cultural safety is the effective nursing practice of a person or family from another culture that is determined by that person or family. Unsafe cultural practise is defined as an action that demeans the cultural identity of a particular person or family (Nursing Council of New Zealand 2002, p. 9).4
Different Perspectives
Every experience involves a web of different people; patients, relatives, and diverse professionals set against an organisational background. Each person involved will have a perspective on the particular situation. These perspectives are often contradictory in that people may see the situation differently. Hence it is necessary for the practitioner to inquire into these different perspectives beyond her or his own partial view. Inquiry into other perspectives is termed empathic inquiry. It is the path to connect with the other and opens a gate to tune into the other’s wavelength and talk about issues.5 Imagine the other’s perspective requires stepping back and taking an objective stance free from one’s own personal perspective. It is akin to putting yourself in the other person’s shoes to consider their view of the situation. Understanding the other’s perspectives gives a bigger picture of the situation and sets up the potential for resolving any ethical dilemma and conflict over what is the right way to respond.
Kant’s moral imperative asserts ‘do as you would be done for’. However, this runs the risk of imposing your own values into the situation. For example, viewing an elderly patient ‘as if that was my mother’. The problem with this principle is that the patient is not your mother and that imposing such a position may be misguided because of identification and emotional entanglement.
Ethical Mapping
The perspectives of others can be mapped (Figure 4.1). Then any conflict between perspectives can be viewed in the light of ethical principles and issues of authority with the intention of understanding the most ethical response to inform future situations. It shifts from an issue of personal responsibility to act for the best to a collective one.
Following the ethical map trail
1 Pose the question – did I/we act for the best,
2 Consider different perspectives commencing with the practitioner’s own perspective,
3 Consider which ethical principles apply in terms of the best decision,
4 Consider what conflict exists between perspectives/values and how these might be resolved, and
5 Consider authority relationships that determined action.
The last point acknowledges the significance of authority in making decisions, no matter the ethical perspective. In reality, decisions are not necessarily made in terms of what’s best for the patient or family, but in terms of professional interest and dominance that is implicit within normal patterns of relating between professionals6. Hence to act for the best, the practitioner may need to challenge the authority of others