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Advances in Nursing Science:
Nursing Ethics

The Ethics of Compliance: A Dialectic

Hess, Dukes Joanne MSN

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Associate Professor, Department of Nursing, New Mexico State University, Las Cruces, New Mexico, Doctoral Student, University of Colorado, School of Nursing, Denver, Colorado.

The author gratefully acknowledges the assistance of Dr. Peggy Chinn and Ms. Kathy Gramling and the encouragement of Dr. Sally Gadow in the development of this article.

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Compliance with prescribed therapeutic regimens is a construct that begs for consideration from an ethical perspective.This article offers a dialectical study of the nurse-client relationship, derived from Gadow's framework of ethical knowledge, that provides an alternative to compliance as context for nursing therapeutics. The dialectic move from compliance as thesis to isolated autonomy as antithesis is explored. Gadow's notion of engagement is elaborated on and offered as a synthesis that transcends the paternalistic and coercive assumptions underlying compliance and overcomes the dilemmas presented by the issues of power, consumerism, and beneficence that are inherent in isolated autonomy.

compliance: n 1. a. The act or process of complying to a desire, demand, or proposal or to coercion. b. Conformity in fulfilling official requirements. 2. A disposition to yield to others.

comply: v 1. To be ceremoniously courteous. 2. To conform or adapt one's actions to another's wishes, to a rule, or to necessity. [1] (p269)

Compliance with prescribed therapeutic regimens has been of documented concern to health care professionals since the time of Hippocrates, who is alleged to have admonished, "Keep watch also on the faults of patients, which makes them lie about the taking of things prescribed." [2] (p297) That concern persists today as reflected in the more than 4,000 published reports on how to control noncompliance [3] and in the investigation of over 250 variables as possible etiologies for compliance found in the research literature. [4] because compliance with clinical prescriptions is assumed to be critical for clients' achievement of optimal health, the phenomenon has been identified as one of interest to nursing, as demonstrated by the inclusion of noncompliance in the profession's diagnostic and intervention taxonomies. [5,6] For nursing, compliance is conceptualized as a desired outcome of the client-nurse relationship to ensure that medical and nursing therapeutics are embraced by the client.

However, compliance with prescribed therapeutic regimens is a phenomenon that begs for consideration from an ethical perspective. The term itself is laden with connotations of paternalism, coercion, and acquiescence. Redefinition of the construct to include collaboration and partnership and the substitution of terms such as "adherence" and "therapeutic alliance" do not address the basic assumptions that underlie the notion of compliance as context for nursing therapeutics. This article proposes an alternative view of the client-nurse relationship derived from the application of Gadow's [7] dialectic of ethical knowledge.

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Philosophy is concerned with the nature of being, the nature of reality. For nursing, philosophy attempts to answer the questions "What is the nature of nursing?" and "What is the nature of the client-nurse relationship?" [8] As a philosophical mode of inquiry that assists in understanding the moral dimensions of human behavior, ethnics attempts to identify that which is good, or desirable, for human beings-that which is moral. For some, the dimension of freedom is included in the conceptualization of ethics as the right thing to do that is free of force, as noted by Engelhardt [9] and Gadow (personal communication, May 30, 1995). As the goal of nursing is a moral one-the good of the one for whom the nurse cares-nurses have a moral imperative to enter into relationships with clients without assumptions of power or coercion. Yet this perspective of the client-nurse relationship contradicts common nursing practice when compliance to prescribed therapeutics is an expectation.

Dialectical study begins where there seems to be a problem and where the problem appears to be a contradiction. [10] Such a contradiction exists between nursing's ontology as a moral art and nursing's practice of that art when compliance is assumed as an expectation. Moreover, dialectic is a liberation of ideas from dogma by discovering what is missing. There is little in nursing and health care that is more dogmatic than the expectation that clients yield to the wishes of others.

Gadow's [7] framework for ethical knowing in nursing is dialectic, adapted from Hegel's elaboration of the philosophy and method. In this framework, there are three levels of ethical knowing in nursing. Each successive level in the dialectic overcomes the inadequacies of the previous level in a process to develop complete understanding of ethical knowing in nursing.

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Immersion: Ethical immediacy

According to Gadow [7] the first level of the dialectic is immediacy, where knowledge is taken for granted and unquestioned. Ethical immediacy is derived from social and community sources, such as religion, profession, culture, family, and society. Immediacy in moral consideration is an unquestioned certainty about what is right and good. It is nondiscursive in that it requires no explanation; the moral view is accepted by the community as is and without question. Gadow contended that when moral certainty is derived from ethical immediacy, "the nurse is immersed uncritically (perhaps unknowingly) in a tradition that gives an ethical reading on a situation, and, second, the nurse apprehends the good by being immersed in the situation itself." [7] (p5)

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Detachment: Ethical universalism

The dialectical move away from immersion and immediacy produces its antithesis, a disengaged and detached objectivity or universalism. This detached objectivity or ethical universalism is manifested in bioethical principles such as justice, autonomy, beneficence, and nonmaleficence that apply to everyone. These principles provide an objective and rational system of moral deliberation as an alternative to immersion in nondiscursive, parochial certainty as a form of ethical knowing. However, ethical principles provide ethical knowledge in a situation only if all situations in which the ethical principle is applied are identical. Moreover, they ignore gender, ethnicity, age, and health status. And where ethical principles conflict with each other in a particular situation and recourse to a hierarchy of principles does not provide adequate ethical knowledge, mental gymnastics occur to redefine the moral situation in order that a particular principle be applied.

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Engagement: Ethical narrative

Gadow [7] described the move beyond rational objectivity in ethics as an "existential turn." In existentialist philosophy, the quest is for understanding of self and what it means to be a self. [11] The self is perceived as a unity without splits among body, rationality, or emotion. Moreover, what individuals have in common-their "universal feature"-is their uniqueness. [7] Ethical universalism cannot acknowledge or address this uniqueness; hence the existential turn.

Within existential philosophy there is a focus on human intersubjectivity and the authentic encounter. [11] It is within this encounter that each person reveals his or her authentic being to the other and in which each person is able to grasp the reality of the other. So beyond merely apprehending people as unique, Gadow [7] contended that the existential turn away from universalism requires engaging them: "Engagement is the opposite of abstract universalism; it is personal responsiveness to the particular other." [7] (p9) Engagement reflects the personal, the contingency of meaning, and the refutation of ethical certainty. And it is through engagement that the ethical narrative is crafted by client and nurse to express the good they are seeking.

Stivers described the sense of self as "essentially a narrative phenomenon." [12] (p412) People conceive of themselves-find meaning and identity-as a result of the stories they tell. For Gadow, narrative meaning is discursive and cocreated by client and nurse. And the ethical knowledge created in narrative through engagement is "particular, contextual, and nongeneralizable" [7] (p11)-it is a relational ethic. The client and nurse are both moral agents, confirming or declining the meaning of the health experience that each offers the other until a narrative is composed that both can accept and act on together in the moral situation. [13] Thus, engagement and the ethical narrative represent the synthesis between immersion and ethical immediacy as thesis and detachment and ethical universalism as antithesis.

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Compliance as thesis

The health care community provides the nurse who is immersed in its ethic the basis for moral certainty that is beyond critical reflection and deliberation. Thus, certainty about the right thing to do is derived from neither the client nor the nurse, but from professional and other norms and expectations. These norms and expectations are articulated in the assumptions underlying the notion of compliance. The assumptions underlying compliance that are held in common by much of the health care community are at the level of ethical immediacy. They are to be accepted uncritically, to be beyond the realm of discourse and reflection, as that community and its professions adopt compliance as context for its therapeutics.

The following are assumptions that underlie the conceptualization of compliance as a desired goal of the client-nurse relationship as context for nursing therapeutics:

• The client's sick role obligation is to seek medical attention and to cooperate with health care professionals. [14]

• Compliance results in cure; noncompliance results in morbidity and mortality. In fact, research has demonstrated that the correlation between compliance and desired outcomes from prescribed therapeutic regimens is not always a positive one. [15,16] Tacchinetti [17] noted that even when client noncompliance resulted in better medical outcomes than would have been achieved through compliance with the clinical prescription, the health care provider still believed that the act of noncompliance was a problem.

• The best possible outcome for the client is a good medical outcome, preferably cure. This assumption reflects the belief that the health care community can determine the best possible outcome for the person.

• The nurse has enough and appropriate knowledge to judge what is in the client's best interest. This assumption presumes that medical and nursing diagnoses are consistently accurate and that the effects of medical and nursing interventions are beyond question.

Despite philosophical and empirical challenges to these assumptions, [18,19] they are not questioned in practice. At the level of ethical immediacy, where the nurse is immersed in a tradition that views compliance as a moral necessity to achieve the good for clients, critical reflection on these assumptions is unnecessary. The assumptions underlying the notion of compliance reflect social, traditional, professional, and even gender bases for certainty at the level of ethical immediacy. Connotations of power, paternalism, and coercion congruent with the definition of compliance pervade these assumptions.

It is at this level of ethical knowledge that client and nurse do what is right, what is best for him or her, as described by authority. Thus, the nurse intervenes to ensure compliance on the part of the client, and the client complies with prescribed therapeutics.

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Isolated autonomy as antithesis

Some authors [18-21] have expressed concern with the morally discomforting aspects of compliance and its assumptions at the level of ethical immediacy. The ethical principle of autonomy is frequently proposed as remedy for the notion of compliance in these critiques. If compliance is viewed as thesis in this dialectic, then autonomy provides the antithesis.

The commonly accepted definition of the principle of autonomy is consistent with Gorovitz' traditional view:

Because we respect individuals, we subscribe to what has been called the Principle of Autonomy, the view that individuals are entitled to be and do as they see fit, so long as they do not violate the comparable rights of others. No person is to be merely the instrument of another person's plans; no person is to be treated in a manner that is blind to the plans, desires, and values that are the fabric of his or her life and identity. Roughly speaking, we believe it is obligatory to leave people alone, unless we have powerful reasons for not doing so. [22] (pp36-37)

Thus, applying the universal principle of autonomy at the ethical knowledge level of detachment and ethical universalism, nurses allow clients to choose freely to be compliant or noncompliant, unless we have powerful reasons for not doing so.

In practice, it is difficult for nurses to accept that the client's right to choose might involve the right to choose wrongly (by objective standards), to the detriment of his or her health. In such situations, the nurse is faced with the competing principle of beneficence. Gorovitz offered the following definition:

Because we care about the well-being of individual persons, we...grant a prominent place in the structure of our moral outlook to...the Principle of Beneficence. That principle, simply stated, holds that one ought to do good. Doing good means benefiting people, helping them, acting-out of respect for their interests-in a way that serves their interests. [22] (p37)

Under the universal principle of beneficence, nurses depend on rationality to expect the client to comply because it is in the person's "best" interest (as defined rationally by experts).

Engelhardt [9] identified the tension that exists between the principles of autonomy and beneficence as a tension between autonomy's deontological and beneficence's teleological nature. Autonomy is deontological in that concrete application of this principle is binding; it grounds rights and obligations independently of concerns for achieving the good in its consequences. The principle of beneficence, in its application to moral situations, grounds rights and obligations in terms of their achieving what is good. Thus, the principle of autonomy takes precedence over that of beneficence. Application of the principle of autonomy is morally obligatory in all cases regardless of its consequences. Application of the principle of beneficence, on the other hand, must be considered in light of the consequences of "doing good."

On the surface, then, it appears that the principle of autonomy, where the client has the moral right to choose between compliance and noncompliance, is the guiding principle for nurses in their relationships with clients. Yet, as Engelhardt pointed out, moral situations exist where there are choices where "not all rights can be satisfied and surely not all goods realized, and where a definitive and all-encompassing hierarchy of rights and goods cannot be established." [9] (p99) The tension between autonomy and beneficence cannot be mitigated in such situations for the nurse operating at the level of ethical universalism.

Assuming an ethical universalism in which respect for client autonomy overrides the nurse's beneficence, two problems arise. First is the problem of the moral position of consumerism, a term applied by Gadow [23] to a pitfall inherent in nonexistential patients' rights advocacy. In respecting client autonomy and self-determination, the role of the nurse easily can become that of technical advisor-one who provides the client with all the information necessary to select among available courses of action without making recommendations of one choice over another for fear that the recommendation becomes coercion. For Gadow, [23] consumerism is a sophisticated form of paternalism that, in the interest of the client's autonomy, forces the person to make important decisions alone, with only technical assistance from the nurse. Moreover, consumerism reflects an indifference to outcome on the part of the nurse as he or she removes the self from clinical decision making. Thus, detachment at the universalism level of ethical knowledge fosters an isolated autonomy.

The second problem emanating from application of the principle of autonomy at this point in the dialectic is that of the implicit and often covert element of coercive power inherent in any client-health care professional relationship. Nurses use coercive power when they communicate to clients statements such as "You need to take your medication to get better." Moreover, nurses and other health care professionals have the potential to use expert power in the form of knowledge that is not readily available to clients. For example, nurses can manipulate client behavior to engage in prescribed therapeutics by describing consequences to that behavior such that the client chooses between apparent selfishness or senselessness or illogicality and responsibility.

Thus, ethical universalism provides an objective certainly found in detachment. This certainly, reflected in rational principles, counters the subjective certainly derived from immersion in the ethical immediacy of community norms and expectations. Within this framework of ethical knowledge, compliance is thesis, and isolated autonomy is antithesis. But autonomy is weakened by the competing principle of beneficence and the notion of consumerism, as well as the covert elements of coercive and expert power in the client-nurse relationship. And as with both levels of ethical knowledge-immersion and detachment-the particular is subjugated to the general; context and client individuality are ignored.

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Engagement as synthesis

Out of compliance as thesis and isolated autonomy as antithesis arises a synthesis-engagement. As synthesis, engagement overcomes the limitations found in compliance at the level of immersion and ethical immediacy and those associated with autonomy at the level of detachment and ethical universalism. Thus, in this synthesis engagement transcends the assumptions that underlie the notion of compliance as thesis and overcomes the dilemmas presented by the issues of power, consumerism, and beneficence that are inherent in isolated autonomy as antithesis.

The assumptions associated with the conceptualization of compliance as a desired goal of the client-nurse relationship become moot in the context of the ethical narrative. No longer are the values and beliefs of the community the only source of moral certainty. Rather, the values and beliefs of the client and nurse and their relationship have a major role in crafting the meaning for the health experience. Client and nurse thereby can act on that meaning together by imagining alternative goals and courses of action to which both can be committed. The assumptions that support the conceptualization of compliance espoused by the health care community cannot express the good that client and nurse are seeking. The norms and expectations of that community can be considered in the crafting of the narrative, but they now are open to discourse and no longer provide unquestioned certainly about what is right and what is good in the relationship, its goals, and the means to achieve those goals.

Nor do engagement and the ethical narrative between client and nurse allow for consumerism and an isolated autonomy. The client is not left alone to make health care decisions with only the technical assistance of the nurse. The nurse no longer is disengaged to prevent her interpretation of and perspective on the meaning of the health experience from interfering with the client's right to self-determination. Engagement insists on discourse between client and nurse in defining the good that is mutually sought and identifying the means for achieving that good. The client remains autonomous in the sense of being self-determining, but that autonomy is no longer in the context of isolation. It demands relationship and an ethical narrative.

Engagement as synthesis transcends the issue of coercive power inherent in both compliance and autonomy as contexts for client-nurse relationships. As noted earlier, autonomy is undermined by the power differential implicit in the client-nurse relationship. Moreover, granting autonomy can be viewed as paternalistic-the client is autonomous because the nurse has given him or her that status. However, this transcendence must be a conscious one; engagement, too, has paternalistic and coercive potential. Engagement requires explicit acknowledgement by the nurse and client of the potential power differential in the relationship. Discourse is needed on the power derived from both the nurse's status as health care professional and the expert knowledge associated with that role. While the nurse may be expert on health conditions in general, the client must be recognized as expert on the self with a particular health condition. Nurses and other health care providers may have knowledge about hypertension, for example, but the client with hypertension is expert on her or his experience with that condition. Thus, nurse and client engage in the ethical narrative, each as expert, bringing the particular and the contextual to that narrative.

Situations occur where the client is unable to assume power. The unconscious client is an example of such a situation. Because there is no verbal discourse, the medium of the ethical narrative does not exist in the usual sense for the expression of this client's values and beliefs. Yet these values and beliefs bef for expression in the formulation of desired goals and the means to achieve those goals. Gadow [24] posited that clinical subjectivity allows the nurse to enter the world of silent patients. The silent patient must be viewed as subject, not object, and nurses need to ask what this person considers as good-not what most people consider good-in this situation. To answer this question, the nurse must first experience her own physical subjectivity. Through this personal subjectivity the nurse is better able to experience the patient's subjectivity to discern the good from the silent patient's perspective. Thus, the patient's voice is heard in this narrative.

Other situations may arise where the client chooses not to codefine goals and therapeutics with the nurse, situations where that power is consciously relinquished to the nurse by the client. The client's physical energy level may be too compromised to thoughtfully attend to decision making, the person may be too overwhelmed emotionally by the nature and significance of the health experience, or the client just might choose to not make decisions about therapeutic goals and methods. In such situations, engagement must continue to create a narrative whereby both client and nurse have a voice to craft and act on the meaning of the health experience. The nurse assists the client in finding and expressing that voice. But even if the client's voice at times is the weaker of the two, a narrative is created. That narrative remains contingent as always, subject to change as the relative strength of each voice changes. And just as with the unconscious client, the nurse must experience the subjectivity of the other in giving voice to the client.

Engagement and the decision to enter into an ethical narrative to craft goals and the means to achieve those goals always must remain a choice for the client at this level of ethical knowing. Engagement is an ideal, not an obligation like compliance or a duty like respect for the principles of autonomy and beneficence. If the ethical is the right thing to do that is free of force, then engagement, too, must be free of force. Engagement occurs as a response to an invitation, not an expectation, by the nurse. If engagement is expectation, then the ethical narrative becomes as paternalistic and coercive as compliance and isolated autonomy. There is no invitation to comply, because the choice between compliance and noncompliance is not acknowledged at the level of ethical immediacy. Nor is there a choice by the client to be autonomous at the level of ethical universalism. Autonomy is an objective principle to be observed, whether desired or not. At the level of the ethical narrative, the client can choose not to engage, not to enter into the narrative, not to co-create meaning of the health experience along with its accompanying goals and therapeutics with the nurse.

And what if the client refuses the invitation to engage? What is the nurse's moral obligation then? How is nursing's goal-the good of the client-then achieved? Nursing's moral imperative to "do good" begs to be addressed. However, the definition of "good" is no longer the same at this level of synthesis in the dialectic as it was at the levels of thesis and antithesis. At the level of compliance, doing good means intervening to create conditions that make it possible for the client to comply. Such interventions identified in the Nursing Interventions Classification include behavior modification, coping enhancement, mutual goal setting, self-modification (by the client), and patient contracting. [6] At the level of autonomy, tension exists between the ethical principle that respects the person's right to self-determination and that of beneficence, the obligation to do good. While philosophically the principle of autonomy takes precedence over doing good, most nurses in practice would subscribe to the caveat in Gorovitz' definition of autonomy: "We believe it is obligatory to leave people alone, unless we have powerful reasons for not doing so." [22] (p37) Doing good, as defined by objective standards and not by client and nurse, may be one such reason.

At the level of engagement, doing good on the part of the nurse involves an invitation to the client to engage in the ethical narrative. The client and nurse imagine different perspectives, different possibilities, in this narrative. The view of the good will be mutually crafted, subject to change, but embraced by both. This contingent good will not be the good as objectively defined in depersonalized, decontextual communitarian or rational perspectives. In the ethical narrative there is no external authority to identify that which is good; its definition comes only from client and nurse. Each must attend to and value the other as the meaning of the health experience is crafted -as sense is made of diagnosis and all its associated ramifications-and goals and the means for achieving those goals are imagined. This meaning constitutes the good.

But if the client chooses not to engage, not to enter into the ethical narrative, only one voice will construct the meaning of the experience-the client's voice. Doing good on the part of the nurse may mean accepting the good created by the unassisted voice of the client. But doing good does not mean doing nothing. The nurse is morally obligated to remain in the relationship, to be authentically there with the client, if for no other purpose than to serve as sounding board to the other's voice. The nurse can enter the process if invited and should ascertain that the client knows that the potential for engagement always exists, but the nurse cannot force it.

Out of compliance as thesis and isolated autonomy as antithesis arises a synthesis-engagement. In the quest to achieve the good for clients, neither of the other levels of this dialectic provides a morally acceptable context for nursing therapeutics. Nursing care begs for client and nurse to engage in order to craft a new form of the good in the ethical narrative. Engagement between client and nurse creates new and previously unimagined possibilities for defining and moving toward desired health outcomes in ways that expectations of compliance found at the ethical knowledge level of immersion and isolated autonomy at the level of detachment cannot. Compliance and isolated autonomy are now irrelevant as contexts for achieving the goal of nursing-the good of those for whom we care.

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autonomy, compliance, dialectic, engagement, ethics

Copyright © 1996 by Aspen Publishers, Inc.