doi: 10.1111/nup.12026

Original article

Nursing and human freedom Mark Risjord PhD Professor, Philosophy Department and the Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA

Abstract

Debates over how to conceptualize the nursing role were prominent in the nursing literature during the latter part of the twentieth century. There were, broadly, two schools of thought. Writers like Henderson and Orem used the idea of a self-care deficit to understand the nurse as doing for the patient what he or she could not do alone. Later writers found this paternalistic and emphasized the importance of the patient’s free will.This essay uses the ideas of positive and negative freedom to explore the differing conceptions of autonomy which are implicit in this debate. The notion of positive freedom has often been criticized as paternalistic, and the criticisms of self-care in the nursing literature echo criticisms from political philosophy. Recent work on relational autonomy and on the relationship between autonomy and identity are used to address these objections. This essay argues for a more nuanced conception of the obligation to support autonomy that includes both positive (freedom to) and negative (freedom from) dimensions. This conception of autonomy provides a moral foundation for conceptualizing nursing in something like Henderson’s terms: as involving the duty to expand the patient’s capacities. The essay concludes by generalizing the lesson. Respect for autonomy on the part of any health care provider requires both respect for the patient’s choices and a commitment to expand the patient’s ability to actualize their choices. Keywords: autonomy, relational autonomy, self-care, Parse, Henderson.

Introduction: autonomy, paternalism, and health care roles The discussion of patient autonomy has been dominated by the dialectic of paternalism. Health care proCorrespondence: Dr Mark Winden Risjord, Professor, Philosophy Department, Emory University, Mailstop: 1560-002-1AA, Atlanta, GA 30322, USA. Tel.: + 1 404 727 2160; fax: + 1 404 727 9425; e-mail: [email protected]

© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 35–45

viders are obligated both to act for the patient’s benefit and to respect patient autonomy.To act for the patient’s benefit but without the patient’s consent is to act paternalistically. If the patient’s capacity to make decisions is sufficiently compromised, then acting without consent is ‘weakly’ paternalistic and is widely held to be morally permissible. To act against a patient’s explicit, uncoerced, and reflectively considered wishes is ‘strongly’ paternalistic and is widely held to be morally impermissible. In this way, the

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problematic of autonomy in health care ethics has revolved around the kinds of diminished capacity for decision making that might license paternalistic intervention. Insofar as the discussion of autonomy in health care has taken treatment decisions to be the paradigmatic exercise of autonomy, it has implicitly focused on the physician–patient relationship. In most health care systems, physicians alone retain the power to prescribe drugs and to order the kinds of life-changing interventions that require careful deliberation. Nurses and other health care providers interact indirectly with such decisions, often providing educational resources or helping patients wrestle with the emotionally fraught complexities of a decision. The authority, however, remains with the physician, and therefore there is an important sense in which the problem of autonomy has been conceptualized in terms of the physician’s role. Nurses, of course, have been deeply concerned with patient autonomy. Indeed, their concern predates much of the literature in bioethics. Nurses were early advocates of truth telling and of involving patients in their treatment. Some of the prominent, early examples of nursing research tested the physiological effects of giving the patient accurate information about medical procedures (Dumas & Leonard, 1963; Johnson, 1973; Hayward, 1975). Because of their role in the health care environment, nurses have historically found themselves (sometimes problematically) in a position of patient advocacy.The nursing role(s) thus provide a different perspective on patient autonomy than what is glimpsed through the lens of the physician’s role. Obviously, there are practical differences. The question for this essay will be conceptual: if we begin from the nurse–patient relationship, how should autonomy be understood?

Autonomy and the nursing role(s) Asking whether the conceptualization of patient autonomy varies among different provider–patient relationships is bound to strike both philosophers and nurses as troubling. Philosophers will argue that autonomy is a fundamental concept of moral thought. To suppose that it varies among different social situations invites moral relativism. While

important, this concern should be deferred until after we have discovered whether – and if so, how – different roles influence the conceptualization of patient autonomy. If there is interesting variation, we can then grapple with its consequences. Nurses will recognize that the question depends on how ‘the nursing role’ is understood. Circumscribing the nursing role is a problem as old as the profession, and there is no consensus on it. Many regard the question as intractable; some dismiss it as irrelevant. There was a lively debate on the character of the nurse’s role that began in the 1960s and continued into the early 1990s. Within this dispute, there were two important lines of thought that, I will argue, implicitly recognized different conceptions of patient autonomy. Making these conceptions explicit might make the question about the nursing role more tractable, even relevant. In the 1950s and 1960s, the writing on nursing theory attended carefully to the relationships among nurses, physicians, patients, and patient families.These nurse scholars were theorizing about the nursing role. Several prominent figures, including Dorothea Orem, Ernestine Wiedenbach, and Virginia Henderson, thought of the role of the nurse as responding to the patient’s inability to meet their own needs. Henderson, in a well-known passage, defined the nursing role this way: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

(Henderson,

1966, p. 17)

Wiedenbach expressed a similar idea in terms of a ‘need-for-help’ that the patient could not meet (Wiedenbach, 1964), and Orem developed the concept of a ‘self-care deficit’ (Orem, 1959). In these texts, the nurse–patient relationship is conceptualized as the nurse filling in those aspects of care that a person would do for him/herself, but cannot because of limitations imposed by ill health. A conception of patient autonomy is built into the idea of the nursing role as addressing a self-care

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deficit. While the patient is conceptualized as a person in need of support, the patient is not the passive recipient of aid. The goal of addressing the self-care needs is to help the patient take over both the physical and intellectual aspects of their own care.A couple of sentences before her famous definition of nursing, Henderson says: If the patient does not understand, accept, and participate in the program planned with and for him, the effort of the medical team is largely wasted. The sooner the person can care for himself, find health information, or even carry out the prescribed treatments, the better off he is.

(Henderson,

1966, p. 16)

Henderson believed that a nurse must respect the patient’s choices and values. At the same time, her conception of the relationship between the patient’s choices and the treatment is richer than mere informed consent. The nurse acts to expand the patient’s capacity for independent action. The patient’s autonomy is not just being respected, it is being promoted. The conception of the nursing role as addressing a self-care deficit was challenged in the 1980s and 1990s on two grounds: that it was an overly paternalistic approach, and that it gave insufficient space for the nurse to act independently of the physician. The earlier conception of the nursing role tended to put the nurse between the patient and the physician. The nurse followed the physician’s orders, so the nursing range of action was circumscribed by the physician’s authority. Conceptualized in this way, the nurse’s autonomy would be limited to patient needs that fell within the scope of physician-prescribed treatment. The recommended role for the nurse thus fit within a hierarchical and paternalistic system. Mitchell and Cody argued that this was not an appropriate nursing role: The nurse is guided to monitor the patient’s choices and to

The argument implicit in this passage may be reformulated and applied to the idea of self-care deficits.1 Even if respect for autonomy demanded that patients are given final say over treatment decisions, patient consent must be informed. The duty to be sure that the patient understands often falls to the nurses, as it should if informational needs are understood as one of the ways that patients manifest a self-care deficit. To fill this deficit, the nurse must contribute ‘some schema of normative standards or beliefs’ about health, disease, and treatment. Because the nurse’s role is circumscribed by the physician’s authority, the nurse seems bound to represent the physician’s view of treatment. The patient’s choice thus seems free only in a thin, meaningless way because the nurse will not have properly brought the patient to his or her full powers unless the choice is consistent with the medical point of view. Mitchell and Cody were writing within the philosophical framework provided by Rosemarie Rizzo Parse, and it is consonant with the nursing theories of Margret Newman, Jean Watson, or Josephine Paterson and Loretta Zderad. This view, based broadly on their understanding of existentialism, hermeneutics, and phenomenology, conceptualizes the role of the nurse in the light of the patient’s absolute free will. The notion of a self-care deficit is taken to be inconsistent with the patient’s freedom to choose insofar as the deficits are identified by the nurse. Indeed, any reference to the nursing ‘helping’ the patient is taken to be inconsistent with respect for patient autonomy (Mitchell & Cody, 1992, p. 58). As Mitchell and Cody understand it, freedom of choice precludes any attempt to help or inform that is not chosen by the patient. On this view, then, autonomy is used as part of an argument that the nurse’s role should not be to intervene in the patient’s health. Rather, the nurse’s role is to ‘be with’ the patient in ‘true presence’. This entails making meaning with the patient; information

determine if they are responsible ones. To carry out this monitoring, the nurse would have to rely on some schema of normative standards or beliefs in order to judge what is

1

‘responsible,’ which is inconsistent practice if the nurse

(1976). However, the object of their critique is a point of agree-

wishes to respect the human science belief that the indi-

ment between Paterson and Zderad’s conception of the nurse’s

vidual is an intentional being possessing free will.

responsibilities and the earlier notions of Henderson, Wieden-

& Cody, 1992, p. 57)

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(Mitchell

Mitchell and Cody are actually critiquing Paterson and Zderad

bach, and Orem.

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or other assistance should be provided only when asked for. These contrasting nursing philosophies present integrated views of the nurse’s relationship to the patient, the nurse’s autonomy vis-a-vis the physician, and the patient’s autonomy. On what we might call, following Mitchell and Cody’s lead, ‘the human science framework’, the obligation to respect autonomy is first and foremost an obligation to not limit the scope the patient’s free choices. The nurse’s role is to understand those choices, but not to critically engage them. This puts the nurse outside of the physician–patient dynamic because the human science framework takes that dynamic to be inherently paternalistic and biologically reductionist. By contrast, the self-care deficit framework (here adopting Orem’s terminology without committing to her particular analysis) sees the nurse’s role as developing and enhancing the patient’s capacities. These include expanding the capacities for decision making, as well as physical abilities. The nurse has a responsibility to identify the needs of the patient, even if there is a parallel responsibility to engage the patient in the process. While the earliest theorists placed the nurse within the scope of the physician, the self-care deficit framework is not logically committed to this picture of nurse–physician relations. The nurse might be quite independent of the physician and still have obligations to meet the patient’s self-care needs.

Positive and negative freedom in the health care context The two conceptions of patient autonomy discussed above have a parallel in the distinction between positive and negative freedom. The distinction is often invoked in political philosophy, and while it has its origins in Hegel’s critique of Kant, recent philosophy traces it to Isaiah Berlin’s 1958 lecture ‘Two Concepts of Liberty’ (Berlin, 1969). As this pair of terms has come to be used in political philosophy, negative freedom is freedom from constraint or interference.A person in chains lacks freedom in the negative sense. Obviously, not just any kind of constraint is a limit to freedom. While gravity might be considered a constraint on my motion, my inability to fly is not a lack of

freedom. Those who invoke the notion of negative freedom typically require that something is an impediment only if it is caused by human action. On the negative conception of freedom, then, a lack of ability to actualize choices makes a person no less free. In the negative sense, I am now free to purchase a sailboat and go sailing because no one is preventing me from doing so. Proponents of positive freedom contend that there is something missing from the negative conception. Because I lack the financial means to purchase a boat, I am not now free to go sailing. Positive freedom is the freedom to do something. As a person’s abilities and capacities increase, so do their positive freedoms. Proponents of positive freedom argue that freedom from constraint (negative freedom) is a necessary component of the concept of freedom, but it is not alone sufficient. The mere ability to make an uncoerced choice is of no value to the agent if the choices cannot be actualized. Freedom, therefore, has a positive (freedom to) as well as a negative (freedom from) dimension. The distinction between positive and negative freedom has gotten some play in the medical humanities literature. It is obviously important for the discussion of whether there is a positive right to health care. Our concern here is not with health care justice, but with understanding what it means to respect the patient’s autonomy. In this latter arena, the distinction has arisen in the context of gerontological health care ethics as the distinction between decisional and executional autonomy. Bart Collopy defined the former as ‘the ability and freedom to make decisions without external coercion or constraint’, while the latter is the ability to ‘act on this decisional autonomy, that is, to carry out and implement personal choices’ (Collopy, 1988, p. 11). Persons in long-term care facilities are particularly vulnerable to loss of their executional autonomy without compromise to their decisional autonomy, but of course the same can be said of almost anyone suffering from an illness sufficiently severe to require nursing attention. Adopting Collopy’s terminology, the difference among conceptions of patient autonomy implicit in the debate over the nursing role can be neatly expressed as the difference between decisional and executional autonomy.

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Nursing and Human Freedom

In political philosophy, the debate over the concept of freedom centres on the role of the state.2 Advocates of negative freedom focus on civil liberties. They often follow Mill in saying that the only appropriate constraints are those that keep each individual from limiting the freedom of others. Advocates of positive freedom argue for regulation of markets, state provision of social services, and so on. Freedom of individuals to actualize their choices depends on their personal resources, they argue, and if a state is to maximize freedom, it must ensure that the citizens meet their basic needs. Berlin’s rich discussion criticizes positive freedom on the grounds that that positive freedom entails paternalism (and in the political context, this means a state that limits individual liberty for the sake of a public good). He presents two arguments for this conclusion. The first argument begins by noting that positive freedom must presuppose a difference between the manifest self and an ‘authentic’ self. Proponents of positive freedom think that negative freedom alone is never enough. Free markets alone, for example, do not guarantee a minimal standard of living for all because, the proponents argue, individuals will act for the sake of their short-run interest, rather than their ‘real’ interest. In general, if negative freedom is insufficient, then acting on one’s own immediate interest must not be sufficient to guarantee well-being. There must be some other choices that do lead to well-being, and these are the choices that an ‘authentic’ self would make. A political system set up to maximize positive freedom will force people to act so as to maximize their ‘real’ interests. And therefore it will inevitably be paternalistic. The second argument contends that positive freedom problematically assumes a conception of the good. The social system must be set up to achieve certain ends, and the proponent of positive freedom holds that these cannot be left to the mere uncoerced choices of individuals (negative freedom). So, there must be some natural hierarchy of goods or values that would not be manifested by unconstrained 2

choice (not captured by markets, for instance). Because it cannot be revealed by unconstrained choices of individuals, this natural hierarchy of goods must not be identifiable by individuals left on their own. It takes some other entity, such as the state, to identify these hidden goods and construct a social system to achieve them.Again, positive freedom leads to paternalism. Notice that the paternalism of this argument is paternalism about ends, while the prior objection was concerned with paternalism about means. In either case, paternalism is inconsistent with respect for the choices of individuals, and for this reason the negative and positive conceptions of freedom are regarded as antithetical. Because of the close parallel between the distinction between positive and negative freedom and the distinction between executional and decisional autonomy, the idea that respect for autonomy includes a commitment to executional autonomy faces the same challenges as the notion of positive freedom. The standard position in medical ethics understands the obligation to respect patient autonomy as respect for the patient’s decisional autonomy. Any further obligation to the patient follows from the obligations of either benevolence or non-malevolence. The alternative view would hold that mere respect for decisional autonomy is inadequate unless it is accompanied by a positive obligation to put the patient in a position to execute the decisions. One might be rightly puzzled by this suggestion. What more is required that is not already required by the combination of (decisional) autonomy and benevolence?3 Moreover, one might use Berlin’s ‘authentic self’ argument to show that executional autonomy would entail paternalism. The problem of the authentic self arises for a position that is committed to executional autonomy in the following way. The standard view holds that the obligation to respect the patient’s choices is sufficient. A patient whose abilities are limited in some way will presumably choose those courses of treatment that will recover the lost ability (or, if not recoverable, mitigate its effects). The patient will thus ask for those

For a good analysis of the issues, see Silier (2005). For a discus-

sion that relates the distinction between positive and negative

3

freedom to public health, see Jennings (2009).

this objection.

© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 35–45

I thank Beverly Whelton for helping me appreciate the force of

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interventions that promote his or her ability to act on choices, and beneficence obligates the health care personnel to supply them (within limits). If positive freedom is more than this, then it must somehow go beyond the choices of the patient.There must be goods that the patient does not recognize, or if recognized, does not choose because of weakness of will or even self-deception. In this way, an obligation to executional autonomy, like positive freedom, presupposes an authentic self who would choose in ways different from the apparent self.An obligation to support executional autonomy would presumably require the health care provider to act on the authentic choices, not the actual ones. But this means that an obligation to support executional autonomy entails strong paternalism. So, if autonomy is more than decisional autonomy plus beneficence, it entails strong paternalism. The argument that an obligation to promote executional autonomy presupposes a particular conception of the good is a direct echo of the argument by Mitchell and Cody, above. Promotion of executional autonomy would suggest that a patient’s choices and the provider’s obligation to act on them are insufficient. The nurse must have some conception of what constitutes good health that goes beyond the patient’s. As Mitchell and Cody pointed out, that conception will be drawn from the scientific, medical conception of health. Presuming that a patient must choose in accordance with the provider’s conception of the good is a strong form of paternalism. Again, a positive view of autonomy leads to paternalism about both means and ends.

Development, relationships, and executional autonomy Developing a conception of autonomy that might fit the self-care deficit conception of the nursing role requires responding to the two foregoing arguments against a positive obligation to support executional autonomy.The first step towards a response is to interrogate the concept of autonomy which underlies them.4 Both sides of the debate take the idea of deci-

sional autonomy to be clear and acceptable; the questions surround the concept of positive, executional autonomy. Both sides assume that a patient has made an autonomous decision when the choice was uncoerced and when the patient had a full understanding of the options and their consequences. This conception is sometimes lampooned as the ‘inner citadel’ view of autonomy. The inner citadel metaphor was used by Berlin to point out how negative freedoms tend to retreat inside the psyche of the person. A paraplegic may have limited mobility and face great barriers to his or her life goals, but in the negative sense, s/he is no less free than any other. S/he has full power of choice, even if limited capacity to enact those choices. Both objections to positive freedom imagine decisional autonomy as choices exercised within such an inner citadel. It is well known, however, that the simple model of decisional autonomy as the freedom to act on one’s strongest desire is philosophically inadequate. The sour grapes puzzle (also known as the satisfied slave) imagines a person who has truncated desires. The slave may have no other desire than to be a slave, and when given the choice, chooses slavery in full knowledge of the conditions and consequences. The individual’s history leads him or her to have only one desire, but the freedom to act on it seems like no freedom at all. The puzzle of the wanton, by contrast, imagines a person who pursues only his current strongest desires, ignoring their coherence or fit with a life plan. Again, this is not the sort of freedom that decisional autonomy is meant to support. Neither of these is a good example of freedom or autonomy, yet both are prima facie entailed by a simple conception of decisional autonomy. And practitioners will recognize that both philosophical puzzles are abstract versions of practical problems encountered by health care professionals. The satisfied slave is a metaphor for the passive patient who desires whatever the nurse desires; the wanton is the health care consumer who context (Jennings, 2009). Jennings proposes a third freedom, ‘freedom through’, to accommodate the relational dimensions of autonomy. This essay argues for a reconceptualization of the first

4

It is on this point that this essay differs from Jennings’ similar

treatment of positive and negative freedom in the public health

two sorts of freedom, making a third unnecessary (at least in patient care settings).

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demands that health care providers satisfy any medically possible choice. A commitment to respect patient autonomy should not entail that the health care provider should acquiesce in the ‘free’ choices of either the passive patient or the wanton consumer. In recent years, some different approaches to autonomy have striven for a richer, more nuanced approach.The decision-making capabilities of an individual need to be understood in the context of the psychological and historical formation of desires, values, and life goals, as well as the role of autonomy in forming a satisfying and stable identity. The relevance of this line of thought to health care ethics is well developed by Bergsma and Thomasma’s (2000) Autonomy and Clinical Medicine. They argue that, from a psychological point of view, autonomy should be considered as part of a person’s identity, in particular as ‘that aspect of identity that permits adjustment and flexibility, when one or another aspect of identity is endangered by a new threat or crisis’ (Bergsma & Thomasma, 2000, p. 18). Health crises, as is well known, can present significant challenges to a person’s sense of who they are, of their role as husband, wife, teacher, or shopkeeper, and of their aspirations for the future. Health status, Bergsma and Thomasma point out, is deeply intertwined with a person’s identity, and therefore, as the dynamic side of identity, autonomy is always engaged with health and illness. And as many who have written in a humanistic vein about health and illness have pointed out, disease and diminished ability are not always limitations on autonomy. Some people respond to such challenges in ways that increase their capacity to adapt, that is, with a growth of autonomy. On the basis of their empirical research, Bergsma and Thomasma suggest that there are two independent dimensions to a person’s autonomy: future orientation and anticipation. Future orientation is the degree to which an individual has ‘a clear, sharp picture of how they hope life will be’ (Bergsma & Thomasma, 2000, p. 7). This is distinct from an individual’s disposition to anticipate and plan for risks or contingencies. Someone may have a clear image of the future, but not be inclined or able to anticipate the steps required to achieve that goal. Or again, someone might be focused on the immediate risks, threats, or

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challenges without having a clear idea of him or herself in the future. Bergsma and Thomasma argue that an individual’s capacity for autonomous response waxes and wanes in both of these two dimensions. Significant illness or sudden changes in ability can force one to rethink short- and long-term goals. This will present different challenges for a person who is not strongly future oriented than for one accustomed to meditating on long-range plans. Similarly, illness may introduce cognitive deficits that make anticipation and response to current challenges difficult, even if it does not affect long-term goals. Bergsma and Thomasma’s work thus renders problematic the idea of an authentic self, hidden in a windowless inner citadel and revealed only by choice behaviour. Psychological identity is always under construction, and so no set of choices at a given time could reveal it. And because autonomy is precisely the capacity to develop an identity, to presume that there is a hidden authentic self is to arbitrarily fix the end point of development. While a richer psychological account of autonomy is valuable, many (including Bergsma and Thomasma) have argued that the conception of autonomy will be inadequate unless the social context is taken into account. Feminist philosophers, in particular, have criticized standard conceptions of autonomy on the grounds that they treat people as isolated decision makers. The problem of the satisfied slave shows that social environment and history may make it impossible for a person to be autonomous. The slave might meet all of the rational and psychological conditions for autonomy, yet the environment might be of such a character that it prevents the full realization of his or her identity. The response has been to develop a relational conception of autonomy, where social context is partly constitutive of individual autonomy (Mackenzie & Stoljar, 2000; Oshana, 2006). The feminist concern with the conditions of oppression has led to a focus on the social conditions that truncate autonomy. The problem for this essay is the converse: what kinds of relationship will develop an individual’s capacities for flexible response to life’s contingencies and for growth toward a full, healthy life? Two lessons relevant to our questions may be drawn from the literature on relational autonomy.

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The first is that the capacity of an individual to develop his or her identity is embodied and situated. Autonomy is not the result of the purely intellectual machinations of an abstract rationality. Some living conditions introduce physical disciplines that either diminish the capacity for identity formation or involve such psychological stress and distortion that it becomes impossible, perhaps permanently so. The examples may be regarded as socially positive, such as military or monastic training, or morally contemptible, such as concentration camps and extreme poverty. Granting that autonomy is a multidimensional aspect of the human psyche, these examples demonstrate that its flowering is only possible as part of specific social arrangements. As many authors have made clear, combining the depravations of illness with an inappropriately structured health care system can create an environment that makes the development of patient autonomy impossible. A second lesson from the literature on relational autonomy is that deliberation is not a solipsistic enterprise. While deliberation requires cognitive capacity for imagining the future, consideration of alternatives, appraising current information, and drawing inferences, it also requires conversation. One solution to the problems of the satisfied slave and the wanton is to introduce more complexity into the individual’s psychological make-up, such as the higher and lower orders of desire proposed by John Stuart Mill or Harry Frankfurt (Frankfurt 1971; Mill, 2002). Such solutions require rational reflection on the lower desires and permit higher-level choices. This will not solve the problem, however, because analogues of the puzzles arise at the higher level (Friedman, 1986). As long as the individual has no external touchstone, there will be no way out of the spiral of selfjustification. Debate and dialogue with others has the potential to introduce new considerations and other perspectives into an individual’s deliberations. It is an expression of autonomy to develop one’s opinions in response to the judgments of others, especially those with whom one has a close personal relationship. Of course, if the conversation partners are insufficiently diverse, then little will be gained. Again, the structure of the social environment is crucial to an individual’s ability to deliberate deeply and thoroughly about his

or her own future. If we add the relational point to the earlier remarks about the way in which autonomy develops, it becomes clear that relationships help individuals compensate for their own limited abilities to plan for the future and to anticipate risk. With these points about autonomy in hand, we can return to the two objections to the idea that there is a positive obligation to support executional autonomy. The first claimed that the attempt to develop a person’s capacity for choice supposes that the nurse knows better than the patient. There must be some ‘authentic’ choices that the nurse can recognize but the patient cannot see. The foregoing considerations show that this assumes a rather thin conception of autonomy. The engagement of nurse and patient should not be conceived as messages telegraphed from one inner citadel to another. No such authentic self hides in the citadel; one’s capacity for autonomy evolves, and it needs to change in response to one’s relationships with others. The obligation to support and develop a person’s capacities is the obligation to engage them in critical conversation. In a health care context, the engagement cannot be purely intellectual, it must also be embodied. The nurse’s role of helping the patient recover or gain capacities for selfcare necessarily encompasses both. Where self-care involves basic elements of life, such as feeding oneself or bathing, moving the patient from dependency to self-care is an increase in autonomy. Expanding the range of self-care enhances autonomy by providing an environment where he or she is better able to grapple with the contingencies of daily life. The intellectual demand of meeting self-care needs is an obligation to critically engage the patient.All too often, nurses are coached to reserve judgment about the patient’s choices. From the point of view of relational autonomy, this is a mistake. There is a difference between being respectful and being uncritical. A nurse who refuses to intellectually engage the patient’s decision-making process is failing to address a central self-care need. Patients who, whether because of an illness or because of a psychological disposition, are struggling with their anticipation of risk and contingency can benefit from the nurse’s assessments.And nurses know well that some patients have difficulty imagining possible new futures after

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injury or disease has dramatically changed their life prospects. Nurses are in an excellent position to help patients think about possibilities that they may consider out of reach or alternatives that they had not previously recognized. Research in nursing and medicine provides reasons for and against choices of treatment, and these reasons need to be treated as reasons by both nurse and patient, not merely as data to be accepted or rejected. Therefore, the second objection against a positive obligation to support executional autonomy misses the mark as well. Contrary to the view expressed by Mitchell and Cody, a health care provider can show respect for the patient’s free choices and at the same time provide a variety of alternative reasons, arguments, and considerations. And they ought to; it is only through such dialogue that respect can truly be shown. Enhancing executional autonomy, understood in terms of self-care, is therefore the obligation to help the patient get into a position where lifestyle choices and identity constitution can be meaningfully engaged. It should be clear at this point why executional autonomy cannot be just decisional autonomy plus beneficence. Decisional autonomy and beneficence alone can justify health care regimes where patient choices are respected, and where patients get adequate medical treatment, yet the patients are constrained physically and intellectually in ways that make them non-autonomous. This is true of some long-term care environments. Beneficent care can be very paternalistic when the patients are poor at risk assessment and planning, and who thereby desire to acquiesce in the provider’s suggestions. A duty to support executional autonomy obligates health care providers to help patients increase their domain of self-care, including the ability to take control of some aspects of their treatment decisions. This view permits criticism of institutional arrangements that are paternalistic, even if the individuals are benevolent and respectful of decisional autonomy.

Beyond paternalism A response to the foregoing arguments might agree that attention to the developmental and relational sides of autonomy is useful, but point out that it does

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not alter the fundamental ethical status of autonomy. Thomas Hill made an argument like this on behalf of the Kantian conception of autonomy (Hill, 1989). Autonomy is integral to one’s status as a person and hence one’s moral status. Therefore, it should not be conceptualized as coming in degrees, as waxing and waning in different social contexts or embodied situations. If we think of autonomy in this way, we risk not treating those with diminished capacities as proper objects of ethical concern. With respect to autonomy, one is either all-in or not playing the game. Hill’s point is entirely sound: a relational or psychologically nuanced conception of autonomy should not be confused with the Kantian use of the concept to define the realm of moral concern. Indeed, the dialectic of paternalism arises partly because of a conflation between the Kantian sense of autonomy (as a moral status) and the obligation to respect a patient’s decisions. Paternalism rushes in to fill the void when autonomy is diminished. But if Hill is right, moral status is never diminished; only a patient’s capacity for reflection and decision making is diminished. We should begin, then, by granting Hill’s point and assuming that the bounds of moral concern have been established. The beings with whom we are concerned are persons with full moral status. Recognizing that part of respecting autonomy is the obligation to help the patient recover or acquire greater capacities for thought and action means that diminished capacity is never a licence to ignore the patient’s perspective. Instead of licencing paternalistic intervention, diminished capacity cries out for development. A positive conception of autonomy thus enables us to reconceptualize the vast territory between complete incapacitation and cleareyed rationality. Instead of finding criteria that justify paternalistic decision making, the moral problem is to identify the social and psychological conditions under which patients can enhance their ability to think through their health care decisions. On the traditional view of negative and positive freedom, positive freedom was thought to entail paternalism and thereby be inconsistent with negative freedom. The richer concepting autonomy made possible by exploring its psychological and relational dimensions shows, we have argued, that positive and

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negative freedom are consistent. A commitment to respect the patient’s choices – decisional autonomy – is consistent with an obligation to help the patient attain the physical and mental self-sufficiency necessary for both making and executing decisions. The well-trodden path by which health care providers travel between respect for the patient’s choice and the countervailing considerations of beneficence and non-malevolence still has a place. But these considerations must be tempered (as they are in good practice settings) by an understanding of the patient’s evolving capacities to anticipate risk and contingency, and to imagine future possibilities. The debate over the nursing role between the human science framework and the self-care framework presupposed, as we saw, a dichotomy between positive and negative conceptions of patient freedom. The arguments above show that an obligation to promote the patient’s capacity for self-care is not paternalistic. Indeed, contrary to the view expressed by Parse and her expositors, full respect for the patient requires that the nurse make judgments about the patient. There is a role for research-based nursing knowledge in the nurse’s relationship with the patient. To refuse to offer help that enhances selfcare, to refuse to offer alternative rationales, and to refuse to critically engage the patient’s deliberations is to abdicate the nurse’s responsibility to support the patient’s autonomy. The foregoing arguments thus provide a moral foundation for the self-care conception of the nursing role espoused by Wiedenbach, Orem, and Henderson. The respect for executional and decisional autonomy that is presupposed by the self-care conception of nursing supports an independent and robust nursing practice. The human science framework is usually recommended on the grounds that it creates a domain for nursing action entirely distinct from the physician’s role. Physicians are portrayed as biologically oriented and paternalistic; nurses are humanistic and support existential choice. The foregoing analysis shows that the human science framework presupposes a conception of autonomy that aligns nursing more strongly with medicine, at least as medicine is portrayed in that literature. The human science framework, like their imagined medical oppo-

nents, takes paternalism to be the threat and the radical affirmation of negative freedom to be the only defence. That is exactly the dialectic of autonomy in traditional medical ethics. By emphasizing action on behalf of the patient’s executional autonomy, the selfcare conception puts nursing in a domain that is not structured by issues about informed consent. Insofar as medicine is imagined to be paternalistic and reductionist (and that should be treated as an open question to be debated, not something to be assumed), the self-care conception better articulates the distinctive character of nursing than does the human science framework. But should we think of the physician’s attitude towards autonomy as so different from the nurse’s? A positive conception of autonomy is made perspicuous by nursing, and commitment to executional autonomy may be deeply embedded in the nursing role(s). But it is not thereby limited to nursing. The lessons may be applied more broadly to enrich the standard treatments of respect for autonomy and to loosen the grip of paternalism on our thinking. Insofar as physicians have authority over prescription, they have a relationship with the patient that will highlight decisional autonomy. These reflections have shown, however, that focus on decisional autonomy alone distorts our understanding of what the respect for autonomy entails. Respect for autonomy on the part of any health care provider requires both respect for the patient’s choices and the commitment to expand the patient’s ability to actualize their choices. The differences in role and relationship dictate only the manner in which these obligations are executed.5

5

Early versions of these ideas were presented at the Emory

Center for Ethics, the 14th International Philosophy of Nursing Conference in Vancouver, and Philosophy in the Nurse’s World: the Politics of Nursing Practice in Banff. Presentation at the Universidad de Granada, Spain, was supported by the Spanish Fulbright Commission. Thank you to all of my colleagues who have commented on these ideas and especially to two anonymous referees for Nursing Philosophy.

© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 35–45

Nursing and Human Freedom

References Bergsma J. & Thomasma D.C. (2000) Autonomy and Clinical Medicine: Renewing the Health Professional Relation with the Patient. Kluwer Academic Publishers, Dordrecht. Berlin I. (1969) Four Essays on Liberty. Oxford University Press, Oxford. Collopy B.J. (1988) Autonomy in long term care: some crucial distinctions. The Gerontologist, 28(Supplement), 10–17. Dumas R.G. & Leonard R.C. (1963) The effect of nursing on the incidence of postoperative vomiting. Nursing Research, 12(1), 12–15. Frankfurt H. (1971) Freedom of the will and the concept of a person. Journal of Philosophy, 68(1), 5–20. Friedman M. (1986) Autonomy and the split-level self. Southern Journal of Philosophy, 24(1), 19–35. Hayward J. (1975) Information: A Prescription Against Pain. Royal College of Nursing, London. Henderson V. (1966) The Nature of Nursing. The Macmillan Company, New York. Hill T.E. Jr (1989) The Kantian conception of autonomy. In: The Inner Citadel: Essays on Individual Autonomy (ed. J. Christman), pp. 91–105. Oxford University Press, Oxford. Jennings B. (2009) Public health and liberty: beyond the Mllian Paradigm. Public Health Ethics, 2(2), 123–134.

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Johnson J.E. (1973) Effects of accurate expectations about sensations on the sensory and distress components of pain. Journal of Personality and Social Psychology, 27(2), 261–275. Mackenzie C. & Stoljar N. (2000) Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self. Oxford University Press, Oxford. Mill J.S. (2002) On Liberty. Dover Publications, New York. Original edition, 1859. Mitchell G.J. & Cody W.K. (1992) Nursing knowledge and human science: ontological and epistemological considerations. Nursing Science Quarterly, 5(2), 54–61. Orem D.E. (1959) Guides for Developing Curricula for the Education of Practical Nurses. Government Printing Office, Washington, DC. Oshana M. (2006) Personal Autonomy in Society. Ashgate Publishing Company, Berlington, VT. Paterson J.G. & Zderad L.T. (1976) Humanistic Nursing. Wiley, New York. Silier Y. (2005) Freedom: Political, Metaphysical, Negative, and Positive. Ashgate Publishing Company, Burlington, VT. Wiedenbach E. (1964) Clinical Nursing: A Helping Art. Springer-Verlag, New York.

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Nursing and human freedom.

Debates over how to conceptualize the nursing role were prominent in the nursing literature during the latter part of the twentieth century. There wer...
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