The Right Thing for the Right Reason
I was reassigned for the 7 p.m. to 7 a.m. shift from post-partum to the adolescent behavioral health unit. I felt comfortable since I had oriented and had worked a few shifts on the adolescent unit, and one of the regular, full-time RN's would be working. I was an hour late because of the shuffling associated with reassignment. I saw Kerry, whom I had worked with before. Kerry knew most of the teens. When I arrived, Kerry had made rounds, retrieved meds from the automated medication dispensing system and was completing patients' Medication Administration Records. I asked how I could help. Kerry replied, “I'm just finishing charting medications; you give the meds, and I'll admit the new patient.”
I was astounded. Kerry was charting medications before they had been given and delegating administration of the meds she had already charted. She was a professional staff member of twenty years, yet she was quite comfortable delegating administration of the meds. She wasn't sneaking, whispering, trying to hide what she was doing, but acting as if charting before giving meds and then passing the responsibility to another RN was usual, reasonable nursing practice.
Thorny questions crowded my mind. I wondered…
“Is medication administration in behavioral health different than in post-partum?”
“Had experience taught Kerry a better way than the ideals of nursing school?”
“Should I tell her about my confusion? I don't want her to think I'm criticizing or judging her. Maybe I should talk with another nurse first? After all, my name won't be on any of the records and she's willing to take responsibility.”
“What if a patient refuses a med? What if a patient is off the unit and I give meds late?”
“What is the right thing to do?”
“What is the efficient, effective thing to do?”
“What responsibility do I have to the patients? the hospital? the nursing staff? the nursing profession? to Kerry? to myself?”
I prayed, “Oh, God, help me know what to do!”
CODE OF ETHICS
My experience illustrates the complex, yet subtle, differences between humanistic and Christian value systems. This contrast is important since Christian nurses may not realize the influence of the humanistic worldview on thought and action. To help us consider the issues, let's contrast humanistic and Christian value systems in light of the American Nurses Association (ANA) Code of Ethics and common ethical issues faced by nurses.
Worldview, ethics and value systems seem far removed as a nurse works his or her way through the myriad decisions made during each shift for each patient. What makes these terms important? Think about value systems and worldviews as eyeglasses or contact lenses. When looking through eyeglasses, the lenses change what you see and how you see it, affecting what you do. Whether or not we realize it, we view the world through the lens of our value system, which causes us to think and act in certain ways. What are humanistic and Christian value system lenses, and how are they different?
Humanistic value system: The lens that places human beings at the center of concern, and from which all other things derive meaning and purpose. This value system says that human beings, and the societies which they evolve, determine what's important, what's good and what's right. No individual human being is more important than another, so unless one's behavior offends what society has decided is right, good and important, each person has a right and responsibility to choose and act on personal values. One person can't tell another person what is right, good or important because that is a personal decision. As the species of human beings evolve, thinking will evolve; what is right, good and important will evolve; and societies will change their guidelines to reflect the evolution of thinking.
Christian value system: The lens that places God, through Jesus Christ, as the origin and center of life. Because God is completely wise, the values articulated in the Bible are the values we espouse and uphold. For a Christian, what God says in the Bible is his Word to all humanity. It is truth whether or not others believe it, agree with it or act on it. Meaning in life derives from the belief that each person is made in the image of God and was created for a specific purpose: to know, to love and to serve God, and to spend eternity with him.
The difference is the amount of attention to the individual making the decision and to the circumstances surrounding the decision.
Moral practice: Doing right things right, for the right reasons. Nurses tend to concentrate on doing things right, leading to legalism and perfectionism in practice decisions. Sometimes doing the right thing gets lost. Our focus can be complying with the prevailing authority without questioning whether the action is legal, ethical or moral. Rationale for action is reduced to: “We've always done it this way” and “That's not our business; we just make sure things run smoothly.”
Both humanistic and Christian value systems respect and expect moral practice. However, an important question is, whose morals? The difference between these two systems tends to be in the rationale for the chosen action. To illustrate, using my experience on the adolescent behavioral health unit, nurses using the two value systems might reason:
“As a Christian, I know passing medications that another nurse has pulled from the automated dispensing system and documented is a felony. The right thing is for Kerry to pass the medications she has charted, since the documentation reflects the person who is legally accountable. The right way to talk with Kerry is to tell the truth in love, and to offer alternatives for my practice while she is passing meds.” Contrast the Christian response with the humanistic response: “Kerry must be swamped to even consider false documentation, which is a felony. She is the one in charge here and is used to the floor and the usual practices. I'm a visitor, helping. I'll tell her I think it's a problem for me to pass meds she has charted, that I'm concerned about the legal implications for my RN license, and that I'd be willing to do other things.”
Sometimes doing the right thing gets lost.
A nurse using a humanistic value system may have come to a similar or different conclusion (i.e., pass or don't pass the meds) than a nurse using a Christian value system. Both nurses may have some of the same concerns. The difference is the amount of attention to the individual making the decision and to the circumstances surrounding the decision.
APPLICATION I: ANA CODE OF ETHICS
The ANA Code of Ethics is the statement of nursing's ethical standard, “an expression of nursing's own understanding of its commitment to society.”1 The code contains statements that explain the intent and depth of each standard, and is a “succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.”2 An ethical code may be viewed from a variety of value systems. Table 1 provides examples of key differences between Christian and humanistic values when interpreting the ANA Code of Ethics. Note that there are similarities and overlaps between the Christian and humanistic views; however, the examples contrast ways in which nurses could think differently using different value systems. A key difference is the emphasis on what or who determines right thinking and action in nursing practice.
APPLICATION II: ETHICAL ISSUES
Nurse ethicists Elsie Bandman and Bertram Bandman suggest that most ethical issues for nurses fall into six categories.3 Each issue may be viewed from a variety of perspectives; however, we will focus on contrasting humanistic and Christian value systems in these six areas.
Quantity vs. quality of life. Christian belief places life in God's hands, while humanistic belief places the evaluation of life in human hands. Scripture teaches that the person finds himself miserable and without hope when life has no value beyond the present (Eph 2:12). From a Christian perspective, can quantity vs. quality of life exist? God lengthens one life (Ps 92:14–15) and shortens another (Ps 102:23). God created each person for a purpose (Col 1:16) and has plans for me that are good and not evil, giving me hope and a future (Jer 29:11). Everything comes from God alone; everything lives by his power; and everything exists for his glory (Rom 11:36). If I understand that God created me in his image and for a specific purpose, then quantity and quality are irrelevant. Rick Warren reminds us in The Purpose Driven Life: What on Earth Am I Here For? that earth is preparation for eternal life with God.4 Because life is temporary, quantity and quality are not factors that concern me—unless a humanistic value system has seeped into my Christian view.
In contrast, if I believe that I decide the purpose of my life and live for my own reasons, quality becomes a hallmark. If life is not of the expected quality, I may think, I don't want to live this way; I am a failure. Humanists also evaluate others' quantity and quality of life, making statements like: “She has outlived her usefulness,” “I don't see how he can live like that,” “I would have blown my brains out long ago if I had to suffer like that.” For a humanist, life ends with death, and since it's my life, I decide the circumstances under which I am willing to live and whether to plan my death or let it happen.
Pro-choice vs. pro-life. The pro-choice versus pro-life issue concerns who chooses what is done to me. The humanist view is that an individual has an inalienable right to life, liberty and the pursuit of happiness. Therefore, I am an autonomous free agent, accountable for the choices I make that concern me. Choices that concern others are negotiated between them and me. When specifically related to the products of conception, because the mass of tissue is in my uterus, it is part of me, and I have the right and obligation to decide what to do about it. I am accountable to myself for my decision.
Christians ask, “Accountable to whom for my choices?” Romans 14:12 states each of us will be accountable to God. Furthermore, we know we existed before we were born because God saw us in utero and planned every day of our lives (Ps 139:16). And regarding all of life, including unborn babies, we do not regard anyone from a purely human point of view or use natural standards of value (2 Cor 5:16).
This difference of accountability comes down to,“ Who is in charge here?” For Christians, God is in charge; for humanists, humans are in charge. For Christians, the choice is God's; for humanists, the choice belongs to the person most affected by the choice. For Christians, earthly accountability is to those in authority (Col 3:22), and ultimately to God. If there is conflict between earthly authority and God's authority, Christians conform to God's commands (Acts 5:29).
Freedom vs. control. At what point is one mature enough to be given freedom, accountability and responsibility? What circumstances require the removal of freedom? Who decides? Under what circumstances does one person or institution take control over another person?
The humanist value system has altered child rearing, believing that if tended and nurtured, children will grow into responsible, accountable adults because they are evolving to a higher level. School systems use discovery learning, believing children have an inborn drive to seek truth and respond to higher-level prompting.
On the other hand, Christians believe God gave humans free will. Because Adam and Eve chose to disobey God, we are separated from him and born with an innate nature bent toward wrongdoing, called a sin nature (Rom 3:9–18). The ultimate choice is to choose God, through Jesus Christ, or to refuse the gift of Jesus Christ.
How do Christians think about control and freedom? The apostle Paul describes the view best, saying the love of Christ controls us (2 Cor 5:14–15), and we freely choose to be controlled by God because we are new creations in Jesus Christ (2 Cor 5:17).
Truth-telling vs. deception. What is truth (Jn 18:38)?Whose truth? In a society in which all things and relationships are relative, truth is elusive. Christians believe in a reality that emits from God, who never changes (Jas 1:17), and truth comes through Jesus
Christ (Jn 1:17). Those who are Christ's followers, learning and obeying his words, will know the truth, truth that sets them free (Jn 8:32). So freedom and truth for Christians are inextricably bound. Conversely, deception and lack of truth is bondage.
For humanists, truth is relative. It depends on the circumstances, on the persons involved, and on the possible outcomes. Humanists regularly find themselves in situations where they wonder which truth is the truth to be told. Christians have less difficulty knowing the truth and, in fact, are expected to tell the truth in love (Eph 4:15).
Distribution of limited resources.
Although Christians believe that God has limitless resources, we are expected to be good stewards of the resources God entrusts to us. We are not expected to ease others' burdens by taking on an unfair load, but we are to share surpluses to meet needs (2 Cor 8:12–15). In God's economy, we are promised that he will supply everything we need according to his riches in Christ Jesus (Phil 4:19). As a nurse, called by God, when needs arise in taking care of my clients, I believe God will supply those needs. Since he fed 5,000 men, plus women and children, with five loaves of bread and two fishes, he can provide the resources I need to care for my assigned clients.
For humanists, gathering and hoarding resources is a wise strategy, and one can't afford to be generous; after all, there is no guarantee there will be enough to meet all needs. In health care, competition occurs for scarce resources. A unit may order more than needed, hoarding for the time when there will be lack. People are told to spend their entire budget. If they don't, there won't be an increase next year. Scarcity of resources is thought to bring out the regressed (rather than evolved) nature of people, and while this is sad, it is inevitable. One must take care of oneself and those for whom one is responsible. Humanists see sharing as a wonderful idea but a luxury rarely affordable.
Empirical knowledge vs. personal belief. Christians believe God created the universe, and new knowledge and research assists in discovering the truth of what God made. Because the Bible is the revealed Word of God, empirical evidence reflects the truth God has already revealed. If research findings contradict the Word of God, we ask if we have understood the Scriptures correctly or if the research was flawed or incomplete, since empirical evidence must align with Scripture.
Humanists, on the other hand, believe new knowledge is being created, not just discovered, so truth is unfolding. Research is the humanist's method of discovery. If empirical evidence doesn't align with an individual's current beliefs and values, a humanist will change beliefs to the more current world understanding or risk clinging to obsolete ideas. Because empirical knowledge often confronts personal belief, humanists say, “Don't let the facts confuse you,” or “I don't care what the research shows; you can do anything with statistics.” When it comes down to belief versus the fact, personal belief wins—whether truth or deception.
IMPLICATIONS FOR ACTION
Christians and humanists have different beliefs, yet both highly respect human beings, so there are similarities. Christians face ethical dilemmas in interacting with the world. When we need wisdom, the all-wise God provides help and direction (Jas 1:2–5). Since the central concern of each value system is quite different—God versus the individual—many beliefs and actions derived from the two value systems are different. A critical difference between Christianity and humanism is the rationale for moral practice. Doing right things right is expected of all nurses, but the core rationale for action—for the right reason—is what separates Christians and humanists.
What can Christian nurses do in practice situations when we encounter ethical dilemmas? Table 2 provides concrete thoughts and actions nurses can utilize to discover God's help and solutions for our complex problems.
As for my situation with Kerry and whether or not to pass the medications, how would you handle this dilemma? What issues would you consider as you determine a course of action? I know I am not alone in this struggle. E-mail or write JCN and share your thoughts.