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ICN
Nursing and Health Policy Perspectives Decolonizing nursing ethics Modern nursing ethics has a rich history dating back to the late 1880s, when the first series of articles on the subject was published (Johnstone In press). Nursing ethics has since developed into a distinctive discipline, distinguishable by a plethora of literature and a growing body of empirical research addressing ethical issues of relevance to the profession and practice of nursing. As rich and distinctive as the discipline of nursing ethics is, a critical dimension of its nature has been underexamined, notably, the overwhelming Western orientation of the core values, concepts, theories, and ways of thinking that shaped it and continue to influence its practice. Especially problematic is the inadvertent imposition of Western nursing ethics as a colonizing methodology in non-Western nursing cultural contexts. The values, concepts and theories that underpin contemporary nursing ethics are very much a product of Western cultures (mainly those of the USA and UK), which have shaped the field (Johnstone In press). Yet the theoretical foundations of nursing ethics have been portrayed as universally applicable in all cultural contexts. The influence of Western nursing ethics has been widespread. This has largely been due to the international dissemination of books and journal articles on nursing ethics published in the English language, which has emerged as the universal medium of communication. In contrast, works on nursing ethics published in other languages are lacking, unknown, or difficult to access, and therefore of little influence outside of their cultural-language contexts. The troubling consequence is that nurses in some non-Western countries (and in some locations where nursing ethics may still have only a fledgling identity and nurses themselves only few local resources) have adopted without question the texts and viewpoints made available via English language publications. This, in turn, has contributed to nurses in some cultural domains occasionally being confused about what nursing ethics is and how best to determine ‘the right thing to do’ in their practice. This is particularly so in contexts where nurses find themselves grappling with Western moral values, knowledge and belief orientations that are at significant odds with their own indigenous cultural worldviews. In such situations emotionally distressing value conflicts have become inevitable, and their resolution often elusive. A notable example of nursing ethics emerging as a colonizing methodology can be found in its ready adoption and
© 2015 International Council of Nurses
operationalisation of the American bioethics approach called ‘ethical principlism’ (encompassing the four principles of autonomy, beneficence, non-maleficence, and justice). Despite ongoing criticism of ethical principlism as a theoretical and decision-making frame, it continues to be taught uncritically to nurses as having ‘universal application’. It is also continually used to frame nursing codes of ethics as well as to inform a range of policy initiatives that stand to have a direct impact on nursing practice (e.g. advance care planning, truth telling and informed consent policies). Without necessary cultural adaptations, however, the application of ethical principlism may not only be inappropriate in given cultural contexts, but can often cause the very moral harms that its application was ostensibly adopted to prevent (Johnstone 2012). A key quest in nursing ethics is to enable freedom in critical moral thinking and, through the exercise of this freedom, the cultivation of a rich tapestry of moral values, beliefs and ‘ways of knowing’ that will result ultimately in excellent (ethical) nursing care. The imposition of a Western orientated nursing ethics has seriously threatened this freedom. Although unintended, the application of Western nursing ethics has sometimes come perilously close to what might be termed ‘ethical ethnocentrism’ and its sequale ‘moral imperialism’. These processes encompass a dominant group’s way of moral knowing and thinking being regarded as not only superior, but ‘right’ and thus something to be applied universally to others whose moral systems are judged to be inferior (Jenkins 2011). The problems of ethical ethnocentrism and moral imperialism in nursing are not new. Questions about whether a universal nursing ethics and, in particular, a universal code of nursing ethics could be feasibly devised were initially raised in the early 1970s. Of particular note were questions about the feasibility of the International Council of Nurses (ICN) 1973 Code for Nurses and its capacity to provide universal guidance to nurses who faced a range of ethical issues particular to their own social, cultural and political environments. In response, ICN encouraged its member states to develop their own national codes for administration within their own respective cultural boundaries and jurisdictions. Arguably one of the most provocative challenges to the assumed universalism of nursing ethics has come from U.S. transcultural nurse theorist Madeleine Leininger. In a landmark essay on the subject, Leininger directly accuses nurse ethicists
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of ‘deliberately avoiding’ the concept of culture and irresponsibly assuming the universality of ‘ethical principles, codes, covenants, and standards of human behavior’ (Leininger 1990, p. 51). Leininger contends that such a stance is not only ill founded, but ethnocentric, and one that would ultimately lead to ‘cultural imposition practices’ (Leininger 1990, p. 51). She concludes that unless the cultural dimensions of ethical care are taken into account it will be ‘virtually impossible for nurses to make appropriate decisions about individuals, clients, families, or groups’ (Leininger 1990, p. 51). Nursing ethics has reached a point in its modern development where it is time to devote attention to decolonizing its unintended impact – i.e. undoing and removing the negative effects of its colonial cultural influences on ‘othered’ systems of nursing ethics. To this end, it would be appropriate for the world’s nurses to collectively formulate an agenda for advancing an authentic global system of nursing ethics that encompasses the rich moral traditions of ‘othered’ cultures and whose voices in nursing ethics have yet to be heard. Undertaking such a project will, however, involve much more than merely ‘adding new voices’ to nursing ethics discourse (Johnstone In press). It will also require building the capacity of nurses in all countries to contribute to this new global agenda. In addition it will require capturing, through the use of decolonized research methodologies (see Smith 2012), the core values, beliefs, knowledge and cultural worldviews indigenous to the world’s nurses in non-Western countries. These must be used to identify, frame
© 2015 International Council of Nurses
and critically examine the ethical issues central to the culturally contextualised profession and practice of nursing. Megan-Jane Johnstone PhD, RN is Professor of Nursing in the School of Nursing and Midwifery, Deakin University, Melbourne, Australia. One of Australia’s foremost nursing scholars, she is renowned internationally for her scholarly research on nursing ethics. Dr Johnstone is the editor of Nursing Ethics, a three-volume major reference work to be released in July 2015 in the Sage Library of Nursing series (www.sagepub.com/books). Contact: [email protected].
References Jenkins, R. (2011) Moral imperialism. Entry In Encyclopedia of Global Justice, (Chatterjee, D.K., ed.). Springer Science and Business Media. Springer Netherlands, Dordrecht/New York, pp. 721–723. Johnstone, M.-J. (2012) Bioethics, Cultural differences and the problem of moral disagreements in end-of-life care: a terror management theory. The Journal of Medicine and Philosophy, 37 (4), 181–200. Johnstone, M.-J., ed. (In press) Nursing Ethics (3 Volumes). Sage Publication, Oxford. Leininger, M. (1990) Culture: the conspicuous missing link to understand ethical and moral dimensions of human care. In Ethical and Moral Dimensions of Care, (Leininger, M., ed.). Wayne State University Press, Detroit, Michigan, pp. 49–66. Smith, L.T. (2012) Decolonizing Methodologies: Research and Indigenous Peoples, 2nd edn. Zed books, London.
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ICN
Nursing and Health Policy Perspectives Decolonizing nursing ethics Modern nursing ethics has a rich history dating back to the late 1880s, when the first series of articles on the subject was published (Johnstone In press). Nursing ethics has since developed into a distinctive discipline, distinguishable by a plethora of literature and a growing body of empirical research addressing ethical issues of relevance to the profession and practice of nursing. As rich and distinctive as the discipline of nursing ethics is, a critical dimension of its nature has been underexamined, notably, the overwhelming Western orientation of the core values, concepts, theories, and ways of thinking that shaped it and continue to influence its practice. Especially problematic is the inadvertent imposition of Western nursing ethics as a colonizing methodology in non-Western nursing cultural contexts. The values, concepts and theories that underpin contemporary nursing ethics are very much a product of Western cultures (mainly those of the USA and UK), which have shaped the field (Johnstone In press). Yet the theoretical foundations of nursing ethics have been portrayed as universally applicable in all cultural contexts. The influence of Western nursing ethics has been widespread. This has largely been due to the international dissemination of books and journal articles on nursing ethics published in the English language, which has emerged as the universal medium of communication. In contrast, works on nursing ethics published in other languages are lacking, unknown, or difficult to access, and therefore of little influence outside of their cultural-language contexts. The troubling consequence is that nurses in some non-Western countries (and in some locations where nursing ethics may still have only a fledgling identity and nurses themselves only few local resources) have adopted without question the texts and viewpoints made available via English language publications. This, in turn, has contributed to nurses in some cultural domains occasionally being confused about what nursing ethics is and how best to determine ‘the right thing to do’ in their practice. This is particularly so in contexts where nurses find themselves grappling with Western moral values, knowledge and belief orientations that are at significant odds with their own indigenous cultural worldviews. In such situations emotionally distressing value conflicts have become inevitable, and their resolution often elusive. A notable example of nursing ethics emerging as a colonizing methodology can be found in its ready adoption and
© 2015 International Council of Nurses
operationalisation of the American bioethics approach called ‘ethical principlism’ (encompassing the four principles of autonomy, beneficence, non-maleficence, and justice). Despite ongoing criticism of ethical principlism as a theoretical and decision-making frame, it continues to be taught uncritically to nurses as having ‘universal application’. It is also continually used to frame nursing codes of ethics as well as to inform a range of policy initiatives that stand to have a direct impact on nursing practice (e.g. advance care planning, truth telling and informed consent policies). Without necessary cultural adaptations, however, the application of ethical principlism may not only be inappropriate in given cultural contexts, but can often cause the very moral harms that its application was ostensibly adopted to prevent (Johnstone 2012). A key quest in nursing ethics is to enable freedom in critical moral thinking and, through the exercise of this freedom, the cultivation of a rich tapestry of moral values, beliefs and ‘ways of knowing’ that will result ultimately in excellent (ethical) nursing care. The imposition of a Western orientated nursing ethics has seriously threatened this freedom. Although unintended, the application of Western nursing ethics has sometimes come perilously close to what might be termed ‘ethical ethnocentrism’ and its sequale ‘moral imperialism’. These processes encompass a dominant group’s way of moral knowing and thinking being regarded as not only superior, but ‘right’ and thus something to be applied universally to others whose moral systems are judged to be inferior (Jenkins 2011). The problems of ethical ethnocentrism and moral imperialism in nursing are not new. Questions about whether a universal nursing ethics and, in particular, a universal code of nursing ethics could be feasibly devised were initially raised in the early 1970s. Of particular note were questions about the feasibility of the International Council of Nurses (ICN) 1973 Code for Nurses and its capacity to provide universal guidance to nurses who faced a range of ethical issues particular to their own social, cultural and political environments. In response, ICN encouraged its member states to develop their own national codes for administration within their own respective cultural boundaries and jurisdictions. Arguably one of the most provocative challenges to the assumed universalism of nursing ethics has come from U.S. transcultural nurse theorist Madeleine Leininger. In a landmark essay on the subject, Leininger directly accuses nurse ethicists
141
142
Nursing and Health Policy Perspectives
of ‘deliberately avoiding’ the concept of culture and irresponsibly assuming the universality of ‘ethical principles, codes, covenants, and standards of human behavior’ (Leininger 1990, p. 51). Leininger contends that such a stance is not only ill founded, but ethnocentric, and one that would ultimately lead to ‘cultural imposition practices’ (Leininger 1990, p. 51). She concludes that unless the cultural dimensions of ethical care are taken into account it will be ‘virtually impossible for nurses to make appropriate decisions about individuals, clients, families, or groups’ (Leininger 1990, p. 51). Nursing ethics has reached a point in its modern development where it is time to devote attention to decolonizing its unintended impact – i.e. undoing and removing the negative effects of its colonial cultural influences on ‘othered’ systems of nursing ethics. To this end, it would be appropriate for the world’s nurses to collectively formulate an agenda for advancing an authentic global system of nursing ethics that encompasses the rich moral traditions of ‘othered’ cultures and whose voices in nursing ethics have yet to be heard. Undertaking such a project will, however, involve much more than merely ‘adding new voices’ to nursing ethics discourse (Johnstone In press). It will also require building the capacity of nurses in all countries to contribute to this new global agenda. In addition it will require capturing, through the use of decolonized research methodologies (see Smith 2012), the core values, beliefs, knowledge and cultural worldviews indigenous to the world’s nurses in non-Western countries. These must be used to identify, frame
© 2015 International Council of Nurses
and critically examine the ethical issues central to the culturally contextualised profession and practice of nursing. Megan-Jane Johnstone PhD, RN is Professor of Nursing in the School of Nursing and Midwifery, Deakin University, Melbourne, Australia. One of Australia’s foremost nursing scholars, she is renowned internationally for her scholarly research on nursing ethics. Dr Johnstone is the editor of Nursing Ethics, a three-volume major reference work to be released in July 2015 in the Sage Library of Nursing series (www.sagepub.com/books). Contact: [email protected].
References Jenkins, R. (2011) Moral imperialism. Entry In Encyclopedia of Global Justice, (Chatterjee, D.K., ed.). Springer Science and Business Media. Springer Netherlands, Dordrecht/New York, pp. 721–723. Johnstone, M.-J. (2012) Bioethics, Cultural differences and the problem of moral disagreements in end-of-life care: a terror management theory. The Journal of Medicine and Philosophy, 37 (4), 181–200. Johnstone, M.-J., ed. (In press) Nursing Ethics (3 Volumes). Sage Publication, Oxford. Leininger, M. (1990) Culture: the conspicuous missing link to understand ethical and moral dimensions of human care. In Ethical and Moral Dimensions of Care, (Leininger, M., ed.). Wayne State University Press, Detroit, Michigan, pp. 49–66. Smith, L.T. (2012) Decolonizing Methodologies: Research and Indigenous Peoples, 2nd edn. Zed books, London.
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
