585630
research-article2015
NSQXXX10.1177/0894318415585630Nursing Science QuarterlyMilton / Ethical Issues
Ethical Issues
The Ethics of Human Freedom and Healthcare Policy: A Nursing Theoretical Perspective
Nursing Science Quarterly 2015, Vol. 28(3) 192–194 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415585630 nsq.sagepub.com
Constance L. Milton, RN; PhD1
Abstract Global healthcare and healthcare policies are evolving with change at a swift pace. Inherent in the discussions of a person’s right to choose health is the notion of freedom. The author in this column compares and contrasts bioethical views of freedom and autonomy with alternative views and possibilities by examining an ethic of freedom grounded from a different paradigm, the humanbecoming nursing theoretical perspective. Keywords ethics, freedom, health policy, humanbecoming Freedom and choice are commonly understood from a normative, bioethical philosophical framework and may be viewed as important to the bioethical principle of autonomy. Hundreds of articles have been written about those who receive healthcare services from healthcare professionals and their inherent rights to choose their healthcare services with pre-designed healthcare plans created for them by healthcare professionals who are viewed as experts in the medical field. The author offers some notions found in current literature on the topic of freedom of choice and then contrasts and discusses these with potential meanings for straight thinking from an alternative philosophical view undergirded by the humanbecoming nursing paradigm (Parse, 2014). Freedom and making healthcare decisions have traditionally been viewed from a normative, bioethical philosophical framework. The term freedom has been linked closely with the Kantian moral ideal and bioethical principle of autonomy and the potential for paternalism (Beauchamp & Childress, 2009). From this perspective, the person (patient) has an intrinsic right to choose healthcare, but healthcare professionals are obligated to act for the patient’s benefit and yet respect a patient’s autonomy. To act for the patient’s benefit (as articulated from a medical model) without the patient’s consent is to act paternalistically. Making treatment decisions for a desired plan of medical care has implicitly been a focus of the physician-patient relationship. In most global healthcare settings, physicians alone retain the power to prescribe drugs and to order life-changing medical interventions that may alter the quality of living for persons who receive the prescribed plan of medical care. In many settings, institutional health maintenance organizations and healthcare systems utilize big data analysis to determine therapeutic priorities and pharmacologic interventions for large numbers of people who share the same medical
diagnoses. These therapeutic plans of medical care are predetermined and physicians follow established protocols according to disease management principles. In these settings, a person’s freedom to choose healthcare may be constrained and limited as healthcare systems are not designed for notions of refusal for specified treatment plans. Healthcare policy and guidelines for the provision and reimbursement of healthcare costs are largely determined through business models that are designed to be streamlined, cost-effective mechanisms that are included as inputs and outputs of systems. The resulting outputs or offering of medical services have costs determined largely through big data analysis and the resulting outcomes for professional practice are to be cost-effective pre-determined evidence-based plans and protocols to be used by physicians and healthcare professionals for the medical treatment of individuals with shared medical diagnoses. Pre-determined medical protocols and pharmacologic treatments potentially constrain those who receive these treatment plans. If a person or family member questions or refuses to participate in the treatment plan, they may be labeled as noncompliant and non-adherent to the treatment protocol. Consistent with several nursing theoretical perspectives, some nurse researchers are included in this movement to increase adherence and often design and participate in research protocols where the desired outcome is to change noncompliant or non-adherent behavior with persons who have been labeled as non-compliant or lacking adherence to a 1
Associate Dean and Professor of Nursing, Azusa Pacific University
Contributing Editor: Constance L. Milton, RN, PhD, Associate Dean and Professor of Nursing, Azusa Pacific, University, 701 E. Foothill Blvd., Azusa, CA, 91702. Email: [email protected]
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
193
Milton / Ethical Issues defined treatment plan for chronic diseases such as diabetes or hypertension.
From its earliest beginnings in the 1950s and 1960s, nurse leaders and theorists have been proponents of responding to the patient’s inability to meet autonomous needs. Virginia Henderson wrote that the unique function of a nurse was to assist the individual, sick or well, in the performance of those activities contributing to health that the individual would perform unaided having the necessary strength or knowledge (Henderson, 1966). Wiedenbach (1964) developed notions that nurses would help patients meet needs that they could not. Orem (1959) developed the concept of a self-care deficit. If the patient has a deficit, the nurse fills it. In these writings, 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. From these perspectives, a person’s freedom to choose may be constrained or altered since the nurses’ role is to fill in or provide the help or solutions that the person cannot provide since the person is too ill, lacks the capacity, or lacks knowledge to make good decisions. From these perspectives, the belief is that autonomy and the freedom of choice may be promoted by expanding the person’s capacity for independent action. In other philosophical writings, freedom within a healthcare context has been viewed and labeled as positive or negative freedom (Berlin, 1969; Collopy, 1988). For these authors, there is a concern of whether there is a positive right to healthcare, whether or not there is the ability to make decisions without coercion or constraint, and whether there is the ability to act upon or carry out individual choices. From these philosophical arguments, human beings are viewed as having freedom of decisional authority if/when they can demonstrate functional knowledge or capacity. The debate over the nursing role in honoring human freedom of another can be expressed as the difference between decisional and executional autonomy (Risjord, 2014). When equating human freedom with functions or deficits, it is the author’s view that human freedom is reduced to a set of conditions or constraints that may potentially dehumanize and diminish what it means to be a person and the noble bearing that is inherent in being human. The following humanbecoming (2014) perspective of human freedom is offered for consideration with implications for the straight thinking ethos of nurse practice.
central disciplinary phenomenon (Parse, 2014). Within the paradigm are philosophical assumptions regarding humanuniverse, the ethos of humanbecoming, and assumptions regarding living quality. All of the assumptions permeate the postulates, themes, and principles of humanbecoming (Parse, 2014). One of the postulates of humanbecoming is freedom, which has unique meaning within the paradigm of humanbecoming (Parse, 2014). In this worldview, human freedom is contextually construed liberation; it is the stuff of being–living in the contextual construction of humanuniverse. Freedom is not a trait or separate aspect to be considered. Rather, it is a coconstituting situational context inherent in personal choosings that give birth to meaning. Freedom is paradoxical in nature in that freedom exists only in a situation and situations can only exist through freedom. Through the unexplainable mystery of being human, no one or no thing is completely knowable or predictable. Freedom is an intentional act of the explicit-tacit knowing of the becoming visible-invisible becoming of the emerging now (Parse, 2014). There is mystery in all dialoguing-listening and yet what is unspoken is not merely something that lacks voice; what remains unsaid is what is not yet shown, what has not yet reached its appearance (Heidegger, 1971). Honoring human freedom from this paradigm follows the belief that human freedom is intentional; it is inherent in the interwoven fabric of what it means to be human and human choices are not predictable. Situations are not to be reconciled or deficits and dilemmas to be overcome. Human freedom is not a human function to be resolved or knowledge that must be added in order to make what is considered an acceptable autonomous decision. Human freedom arises as a cocreated situation of uniqueness bounded by earlier choosings, yet emerging with new meanings choices and decisions, experienced as living in the moment. Human beings are seamless symphonies of becoming and the ethos of nursing or ethical phenomenon of concern to nursing is dignity. Honoring human freedom is an offering of solemn regard and respect for human presence and human dignity. Honoring human dignity is an acknowledgment of human freedom in its situational context. Health decisions are made in unpredictable, mysterious moments coconstituted with all of the person’s unbounded histories and relationships emerging in the moment with unique meanings for what is not yet visible. What is important to another may never be known or made explicit to the nurse or healthcare professional. As the discipline of nursing seeks to serve humankind, may we consider health policies that are also honoring to humankind?
Freedom and the Humanbecoming Paradigm
Honoring Human Freedom in Health Policy
The humanbecoming paradigm has emerged as a unique worldview from other schools of thought, distinct from the metaparadigm conceptualization and all other paradigm conceptualizations found in the discipline of nursing. It contains an ontology, epistemology, and methodologies focusing on a
Health policies exist to provide guidelines and expectations for those who provide professional healthcare services and they also exist to protect and serve those who receive professional healthcare services. As health policies proliferate from government organizations as well as in statements from professional
Early Nurse Theorist Views on Freedom
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
194
Nursing Science Quarterly 28(3)
medical and nursing organizations, the importance of honoring human freedom and choice should be inherent and visible to all. The author encourages members of the discipline to engage in deep thinking and encourages nurse scholars to begin new paradigmatic thinking with conceptualizations that honor human dignity and freedom in its practice and policy making. Simply focusing on adherence to medical treatments may be dehumanizing to those we serve. Their voices and participation must be heard and honored in all of our decision-making and policy strategies. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References Beauchamp, T., & Childress, J.F. (2009). Principles of biomedical ethics. (6th ed.). New York: Oxford University Press. Berlin, L. (1069). Four essays on liberty. Oxford: Oxford University Press. Collopy, B.J. (1988). Autonomy in long term care: Some crucial distinctions. The Gerontologist, 28, 10-17. Heidegger, M. (1971). On the way to language (P.D. Hertz, Trans.). San Francisco: Harper. Henderson, V. (1966). The nature of nursing. New York: Macmillan. Orem, D.E. (1959). Guides for developing curricula for the education of practical nurses. Washington, D.C.: Government Printing Office. Parse, R. R. (2014). The humanbecoming paradigm: A transformational worldview. Pittsburgh, PA: Discovery International. Risjord, M. (2014). Nursing and human freedom. Nursing Philosophy, 15, 35-45. Wiedenbach, E. (1964). Clinical nursing: A helping art. New York: Springer-Verlag.
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
research-article2015
NSQXXX10.1177/0894318415585630Nursing Science QuarterlyMilton / Ethical Issues
Ethical Issues
The Ethics of Human Freedom and Healthcare Policy: A Nursing Theoretical Perspective
Nursing Science Quarterly 2015, Vol. 28(3) 192–194 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415585630 nsq.sagepub.com
Constance L. Milton, RN; PhD1
Abstract Global healthcare and healthcare policies are evolving with change at a swift pace. Inherent in the discussions of a person’s right to choose health is the notion of freedom. The author in this column compares and contrasts bioethical views of freedom and autonomy with alternative views and possibilities by examining an ethic of freedom grounded from a different paradigm, the humanbecoming nursing theoretical perspective. Keywords ethics, freedom, health policy, humanbecoming Freedom and choice are commonly understood from a normative, bioethical philosophical framework and may be viewed as important to the bioethical principle of autonomy. Hundreds of articles have been written about those who receive healthcare services from healthcare professionals and their inherent rights to choose their healthcare services with pre-designed healthcare plans created for them by healthcare professionals who are viewed as experts in the medical field. The author offers some notions found in current literature on the topic of freedom of choice and then contrasts and discusses these with potential meanings for straight thinking from an alternative philosophical view undergirded by the humanbecoming nursing paradigm (Parse, 2014). Freedom and making healthcare decisions have traditionally been viewed from a normative, bioethical philosophical framework. The term freedom has been linked closely with the Kantian moral ideal and bioethical principle of autonomy and the potential for paternalism (Beauchamp & Childress, 2009). From this perspective, the person (patient) has an intrinsic right to choose healthcare, but healthcare professionals are obligated to act for the patient’s benefit and yet respect a patient’s autonomy. To act for the patient’s benefit (as articulated from a medical model) without the patient’s consent is to act paternalistically. Making treatment decisions for a desired plan of medical care has implicitly been a focus of the physician-patient relationship. In most global healthcare settings, physicians alone retain the power to prescribe drugs and to order life-changing medical interventions that may alter the quality of living for persons who receive the prescribed plan of medical care. In many settings, institutional health maintenance organizations and healthcare systems utilize big data analysis to determine therapeutic priorities and pharmacologic interventions for large numbers of people who share the same medical
diagnoses. These therapeutic plans of medical care are predetermined and physicians follow established protocols according to disease management principles. In these settings, a person’s freedom to choose healthcare may be constrained and limited as healthcare systems are not designed for notions of refusal for specified treatment plans. Healthcare policy and guidelines for the provision and reimbursement of healthcare costs are largely determined through business models that are designed to be streamlined, cost-effective mechanisms that are included as inputs and outputs of systems. The resulting outputs or offering of medical services have costs determined largely through big data analysis and the resulting outcomes for professional practice are to be cost-effective pre-determined evidence-based plans and protocols to be used by physicians and healthcare professionals for the medical treatment of individuals with shared medical diagnoses. Pre-determined medical protocols and pharmacologic treatments potentially constrain those who receive these treatment plans. If a person or family member questions or refuses to participate in the treatment plan, they may be labeled as noncompliant and non-adherent to the treatment protocol. Consistent with several nursing theoretical perspectives, some nurse researchers are included in this movement to increase adherence and often design and participate in research protocols where the desired outcome is to change noncompliant or non-adherent behavior with persons who have been labeled as non-compliant or lacking adherence to a 1
Associate Dean and Professor of Nursing, Azusa Pacific University
Contributing Editor: Constance L. Milton, RN, PhD, Associate Dean and Professor of Nursing, Azusa Pacific, University, 701 E. Foothill Blvd., Azusa, CA, 91702. Email: [email protected]
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
193
Milton / Ethical Issues defined treatment plan for chronic diseases such as diabetes or hypertension.
From its earliest beginnings in the 1950s and 1960s, nurse leaders and theorists have been proponents of responding to the patient’s inability to meet autonomous needs. Virginia Henderson wrote that the unique function of a nurse was to assist the individual, sick or well, in the performance of those activities contributing to health that the individual would perform unaided having the necessary strength or knowledge (Henderson, 1966). Wiedenbach (1964) developed notions that nurses would help patients meet needs that they could not. Orem (1959) developed the concept of a self-care deficit. If the patient has a deficit, the nurse fills it. In these writings, 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. From these perspectives, a person’s freedom to choose may be constrained or altered since the nurses’ role is to fill in or provide the help or solutions that the person cannot provide since the person is too ill, lacks the capacity, or lacks knowledge to make good decisions. From these perspectives, the belief is that autonomy and the freedom of choice may be promoted by expanding the person’s capacity for independent action. In other philosophical writings, freedom within a healthcare context has been viewed and labeled as positive or negative freedom (Berlin, 1969; Collopy, 1988). For these authors, there is a concern of whether there is a positive right to healthcare, whether or not there is the ability to make decisions without coercion or constraint, and whether there is the ability to act upon or carry out individual choices. From these philosophical arguments, human beings are viewed as having freedom of decisional authority if/when they can demonstrate functional knowledge or capacity. The debate over the nursing role in honoring human freedom of another can be expressed as the difference between decisional and executional autonomy (Risjord, 2014). When equating human freedom with functions or deficits, it is the author’s view that human freedom is reduced to a set of conditions or constraints that may potentially dehumanize and diminish what it means to be a person and the noble bearing that is inherent in being human. The following humanbecoming (2014) perspective of human freedom is offered for consideration with implications for the straight thinking ethos of nurse practice.
central disciplinary phenomenon (Parse, 2014). Within the paradigm are philosophical assumptions regarding humanuniverse, the ethos of humanbecoming, and assumptions regarding living quality. All of the assumptions permeate the postulates, themes, and principles of humanbecoming (Parse, 2014). One of the postulates of humanbecoming is freedom, which has unique meaning within the paradigm of humanbecoming (Parse, 2014). In this worldview, human freedom is contextually construed liberation; it is the stuff of being–living in the contextual construction of humanuniverse. Freedom is not a trait or separate aspect to be considered. Rather, it is a coconstituting situational context inherent in personal choosings that give birth to meaning. Freedom is paradoxical in nature in that freedom exists only in a situation and situations can only exist through freedom. Through the unexplainable mystery of being human, no one or no thing is completely knowable or predictable. Freedom is an intentional act of the explicit-tacit knowing of the becoming visible-invisible becoming of the emerging now (Parse, 2014). There is mystery in all dialoguing-listening and yet what is unspoken is not merely something that lacks voice; what remains unsaid is what is not yet shown, what has not yet reached its appearance (Heidegger, 1971). Honoring human freedom from this paradigm follows the belief that human freedom is intentional; it is inherent in the interwoven fabric of what it means to be human and human choices are not predictable. Situations are not to be reconciled or deficits and dilemmas to be overcome. Human freedom is not a human function to be resolved or knowledge that must be added in order to make what is considered an acceptable autonomous decision. Human freedom arises as a cocreated situation of uniqueness bounded by earlier choosings, yet emerging with new meanings choices and decisions, experienced as living in the moment. Human beings are seamless symphonies of becoming and the ethos of nursing or ethical phenomenon of concern to nursing is dignity. Honoring human freedom is an offering of solemn regard and respect for human presence and human dignity. Honoring human dignity is an acknowledgment of human freedom in its situational context. Health decisions are made in unpredictable, mysterious moments coconstituted with all of the person’s unbounded histories and relationships emerging in the moment with unique meanings for what is not yet visible. What is important to another may never be known or made explicit to the nurse or healthcare professional. As the discipline of nursing seeks to serve humankind, may we consider health policies that are also honoring to humankind?
Freedom and the Humanbecoming Paradigm
Honoring Human Freedom in Health Policy
The humanbecoming paradigm has emerged as a unique worldview from other schools of thought, distinct from the metaparadigm conceptualization and all other paradigm conceptualizations found in the discipline of nursing. It contains an ontology, epistemology, and methodologies focusing on a
Health policies exist to provide guidelines and expectations for those who provide professional healthcare services and they also exist to protect and serve those who receive professional healthcare services. As health policies proliferate from government organizations as well as in statements from professional
Early Nurse Theorist Views on Freedom
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
194
Nursing Science Quarterly 28(3)
medical and nursing organizations, the importance of honoring human freedom and choice should be inherent and visible to all. The author encourages members of the discipline to engage in deep thinking and encourages nurse scholars to begin new paradigmatic thinking with conceptualizations that honor human dignity and freedom in its practice and policy making. Simply focusing on adherence to medical treatments may be dehumanizing to those we serve. Their voices and participation must be heard and honored in all of our decision-making and policy strategies. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References Beauchamp, T., & Childress, J.F. (2009). Principles of biomedical ethics. (6th ed.). New York: Oxford University Press. Berlin, L. (1069). Four essays on liberty. Oxford: Oxford University Press. Collopy, B.J. (1988). Autonomy in long term care: Some crucial distinctions. The Gerontologist, 28, 10-17. Heidegger, M. (1971). On the way to language (P.D. Hertz, Trans.). San Francisco: Harper. Henderson, V. (1966). The nature of nursing. New York: Macmillan. Orem, D.E. (1959). Guides for developing curricula for the education of practical nurses. Washington, D.C.: Government Printing Office. Parse, R. R. (2014). The humanbecoming paradigm: A transformational worldview. Pittsburgh, PA: Discovery International. Risjord, M. (2014). Nursing and human freedom. Nursing Philosophy, 15, 35-45. Wiedenbach, E. (1964). Clinical nursing: A helping art. New York: Springer-Verlag.
Downloaded from nsq.sagepub.com at University of Exeter on June 4, 2016
