Partiality and Justice in Nursing Care

Marita Nordhaug

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351812511
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Partiality and Justice in Nursing Care examines the conflicting normative claims of partiality and impartiality in nursing care, looking in depth at how to reconcile reasonable concerns for one particular patient with equally important concerns for the maximisation of health-related welfare for all with relevant nursing-care needs, in a resource-limited setting.

Drawing on moral philosophy, this book explores how discussions of partiality and impartiality in moral philosophy can have relevance to the professional context of clinical nursing care as well as in nursing ethics in general. It develops a framework for normative nursing ethics that incorporates a notion of permissible partiality, and specifies which concerns an ethics of nursing care should entail when balancing partialist and impartialist concerns. At the same time, Nordhaug argues that this partiality must also be constrained by both principled and context-sensitive assessments of patients' needs, as well as of the role-relative deontological restriction of minimising harm, something that could be mitigated by institutional and organisational arrangements.

This thought-provoking volume is an important contribution to nursing ethics and philosophy.

1 Partiality and impartiality in nursing care

Impartiality and distributive justice in clinical nursing care

As nurses fulfil an institutional role, they are expected to be impartial in distributing nursing care. In this book impartiality is tied to ideas of distributive justice.¹ As said in the introduction, I take impartiality to imply giving equal concern for all patients on the basis of their need for health care, as well as maximising nursing care for all with a relevant need and claim for such care. For the sake of convenience, let us term these notions as ‘the rule of equality’ and ‘the rule of maximising care’, respectively.

Imagine a nurse, Kate, who is responsible for the nursing care of five patients in a hospital ward. Kate is expected to distribute nursing care to these five patients impartially. As will be further argued in the second chapter of this book, nurses should, for instance, not distribute care according to gender differences or certain personal preferences or prejudices. This would be considered an example of bias both from the perspective of impartiality, and also from the perspective of partiality, as I will define it. So what does impartiality amount to in nursing care?

Brad Hooker (2010) has identified three levels for directing (moral) impartial assessments: (1) one may assess whether (good) moral rules are applied impartially; (2) one should use impartial benevolence as the single, direct guide to practical decision-making; and (3) from an impartial point of view, one could assess the content of first-order (good) moral rules. This is far from capturing the whole story about impartiality. My purpose here is simply to outline what I take to be the main aspects of impartiality as a component of justice in nursing care.²

Impartial application of moral rules

When one is guided solely by the distinctions identified as relevant by a certain rule, one is impartially applying that rule. This is how Hooker (2010) characterises impartial application of first-level moral rules, i.e. the level of practical decision-making. Note that Hooker discusses the impartial application of the rule. Hence, the content of the rule does not have to demand impartiality. In this sense, impartiality is considered as a formal component of morality. Applying a rule impartially is not, according to Hooker, incompatible with the compliance with a rule of non-impartial content. Accordingly, impartial application of a rule could include compliance with rules that specify who is benefited or harmed (and to what extent), as well as rules which do not make such distinctions. The rules against lying, stealing, and breaking the law are instantiations of the latter (Hooker, 2010). Impartial compliance with, for instance, the rule against breaking promises implies never breaking a promise to anyone (Hooker, 2010). Hooker then suggests examples of rules which describe who should benefit or be harmed. An instantiation of such a rule is one which states that friends and family should receive a fixed amount when you allocate your own resources (Hooker, 2010).

An important insight here is that partiality can be legitimate at the practical level of impartial assessment. Such a view is also in line with Brian Barry’s (1995) idea of first-order impartiality. Barry argues that partiality might be permissible at this level of practical decision-making and action in daily life. According to Barry, a proper distinction between first-order and second-order impartiality is central for the discussion of partiality and impartiality. Indeed, he argues that the debates between partialists and impartialists would be dismissed if this distinction were made properly. Barry argues that on a general level impartiality is and should be required. I return to this in a short while. The problem is that debates on partiality and impartiality most often deal with our private moral lives. Barry points out that those who occupy institutional roles should be committed to a higher degree of impartiality in their decisions and actions. As for the example of the nurse, Kate, it is important to bear in mind that she governs the distribution of public, collective resources, not her own, personal resources. This particular fact is a compelling reason for why those who occupy an institutional role are supposed to be impartial. Hence, even if we accept the claim made by both Hooker and Barry, that partiality might be permissible at the practical level in everyday life, partiality seems to require another sort of justification for professional life.

Let us again consider Hooker’s account of impartial application of (first-order) moral rules. Take the rather general rule that ‘any nurse should provide adequate and individualised nursing care to those in need of it’. An impartial application of this rule requires that anyone with a need for nursing care should receive (adequate and individualised) nursing care. If Kate sees to it that, say, three out of the five patients receive adequate and individualised nursing care, she does not apply this rule impartially. Imagine then another rule stating that only patients under the age of 90 years should receive nursing care. If two out of Kate’s five patients were above this age limit, an impartial application of this rule consists of not attending to the nursing care needs of these two patients. This is so because the rule itself impels Kate to act according to the age limit. That is, the rule itself defines who should benefit. If she nevertheless provides (adequate and individualised) nursing care to all these five patients, she is not applying the rule impartially. Fortunately, this second rule is not very likely to arise in the real world – it is hardly a good moral rule. For the sake of the contention here, we could say that to qualify as a good moral rule, the rule has to be impartially defensible (Hooker, 2010). Hooker’s argument is that for a rule to be impartially defensible (and thereby good, according to Hooker), it must give equal weight to the good of all parties involved. This leads us to Hooker’s second approach to comprehending impartiality.

Impartial benevolence and practical reasoning

Hooker argues for impartial benevolence as the only direct determiner of everyday practical decision-making. This is an (act-)utilitarian approach for making impartial assessments. In this sense impartial benevolence should be understood as equal concern for the good of each (Hooker, 2010). Equal concern for the good of each, Hooker argues, implies that benefit or harm to one individual have the same-size benefit or harm to any other individual. According to Hooker this form of impartial assessment is only sometimes appropriate in our ordinary everyday lives. In fact, if the notion of impartial benevolence was interpreted literally, the results might be somewhat absurd, as Hooker writes:

You might know more about how to benefit your family and friends than you know how to benefit strangers. Thus you might attend to your family and friends more than to others – but not because you have greater concern for your family and friends. On the contrary, whenever you were sure that doing something for a stranger would benefit the stranger at least a little more than doing the same thing for yourself or your family member or friend, you would benefit the stranger. If you could save three lives by giving to one person one of your kidneys, to the second person the other of your kidneys, and to the third person your heart, you would do so.

(Hooker, 2010, p. 31)

But impartial benevolence is required, he argues, if one is occupying certain official roles. However, is it not the case that a requirement to maximise net aggregate benefit would be too demanding in certain official roles, such as in nursing care? Hooker acknowledges that unconstrained impartiality could sometimes be inappropriate even in official roles. For instance, there are deontological prohibitions against murder, torture, robbery, and fraud (Hooker, 2010). To point out extreme actions such as torture and robbery as exceptions to the utilitarian claim is not very helpful for my purpose here. The choice between, say, fraud and impartial benevolence, is not likely to arise in the context of nursing care. It is more likely that, for instance, a deontological restriction against harming might conflict with impartial benevolence. In health care, a principle of not harming is fundamental. Simultaneously, some form and some degree of harm is unavoidable. For instance, as Edwards (1996) points out, a surgeon inflicts physical harm on a patient undergoing an appendectomy when he cuts open the patient’s abdomen. One can also imagine the harm inflicted on a mentally ill patient who is (legally) forced into medical treatment or hospital admission (Edwards, 1996). In such cases, a prohibition against harming the patients as an avoidable part of the procedure is (at least ordinarily) ruled out by concern for the good of the patients. In other words, harming a patient may in certain situations be the precondition for benefiting the patient.

In other situations, there is an absolute prohibition against harming patients. The problem is that it is not always obvious how to comprehend the notion of harm. Consider Kate again. Let us say that one of her patients suffers from unstable diabetes mellitus and needs an injection of insulin one hour prior to breakfast. Suppose also that this patient is demented, though competent enough to give consent, and moreover refuses the injection. As a result, Kate may need quite lot of time to deal with this situation. She must communicate efficiently with this patient, assess the patient’s blood sugar, discuss the situation with the physician, and so on. If Kate could maximise net aggregate benefit for her five patients by postponing the injection of insulin, is she morally permitted (or even required) to do so? Not so if the patient is physically harmed³ by not getting the injection. This is due to the severity of need. If the severity of this patient’s need overrides the other patients’ (net aggregate) needs, a prohibition against postponing this situation rules out impartial benevolence.

Imagine then another nurse, Jason. As a community nurse on nightshift, Jason is responsible for the nursing care needs of fifteen patients. If Jason could maximise the net benefit of all these patients by putting sanitary pads onto three of the patients (in order to save the time it would have taken to take these patients to the bathroom), should he do so? There is no deontological prohibition against the action itself. But there is a prohibition against harming patients. The question is whether Jason harms these three patients if he chooses to do so. Suppose none of these patients would refuse to wear sanitary pads, say, because they are severely demented and have lost the ability to cognitively grasp their situations. In a radical sense, then, one might say that these patients would not suffer if they were to use pads instead of going to the toilet. Their needs are not ignored, one may say. In that sense, Jason is not breaking the deontological prohibition against harming since the rule does not seem to apply to the situation. If this is so, he should act according to the principle of impartial benevolence. But I would object to this conclusion. After all, is not humiliation and disrespect for patients’ integrity as harmful as the physical harm that might be caused by having a wet pad the whole night through? Indeed, this is the core of the ethical problem facing Jason: On what grounds should someone’s right to adequate and individualised nursing care be violated more than someone else’s? The point here is that harm can take many forms. Any assessment of harm also requires contextual sensitivity. Therefore, it might turn out that a deontological prohibition against harming frequently conflicts with or even rules out impartial benevolence. But this does not in itself imply that the rule of impartial benevolence falls short of being a good moral rule. It only shows that impartial benevolence is challenged as a prima facie rule. In the third section of Chapter 5 I return to the challenging claims of consequentialism (and utilitarianism) and the possible deontological restrictions against it.

Impartial assessment of moral rules and action

At the level of practical decision-making we saw that impartiality leaves some scope for partial action. More precisely, one is permitted to follow partial rules as long as these rules are applied impartially. Hooker’s worry seems to be that one ends up favouring rules that are partial. Therefore, he argues that the rule upon which one acts should be impartially justified (Hooker, 2010). He asserts that good moral rules are those that place equal value on the good of all people involved.

There are of course other approaches for impartial assessments than that of Hooker’s rule consequentialism. One is the view that impartial justification is ensured if the principle (upon which one acts) cannot be reasonably rejected by any individual.⁴ This is Barry’s contractarian view of second-order impartiality. As referred to above, Barry argues that partiality is permissible at the level of practical decision-making and action. But at the level of principles, one should ensure impartial justification. This is also the level at which the degree of partiality should be refined (Barry, 1995). According to this idea, institutions should be arranged in a way that anyone reasonably would accept. In health care, impartiality is directed both to health care receivers and to health care providers. For instance, the superior and macro level of health care should ensure that every citizen acquires certain basic rights to health care. At the same time, certain principles and rules are developed at this level as to ensure health care professionals act according to patients’ rights.⁵ According to Barry’s position, then, we must reasonably expect that anyone would accept either kind of principle.

Consider again the rule⁶ where ‘only patients under the age of 90 years old should receive nursing care’. Previously I said that this rule is not a good moral rule. Why is this so? For one thing, it is intuitively absurd. Besides, according to Barry’s account of second-order impartiality, it is not likely that anyone would reasonably accept it.⁷ Second, it contravenes what I called the ‘rule of equality’ (i.e. equal concern for all patients on the basis of their need for health care). Let us for a moment call these two rules R¹ and R², respectively. According to Hooker’s position, R¹ would not qualify as a good moral rule since it does not apply equal concern to the good of each person involved. Why then, is R² a good moral rule? According to Hooker’s account, it surely is. That is, for an impartial justification we should ask the questions: ‘impartial with respect to what and with regard to whom?’ As for R² the answer is ‘impartial with regard to needs of health care and with regard to any patient’. R² then states that each patient should be accorded equal concern for his or her health care needs (implying equal respect for all patients’ needs). This rather general rule seems to correspond with Hooker’s account of a good moral rule. Could R² be impartially justified at the level of principles (i.e. as second-order impartiality)? Most probably yes. The basic premise for impartial justification is that no one would reasonably reject the principle. Health care is a collective good from which everyone benefits, more or less, during their lifetime. The principle should therefore hold equally for everyone. Health care institutions that adapt R² therefore seem to meet the demands of second-order impartiality.

Nevertheless, a higher-level impartial justification does not guarantee an impartial application of the principle, nor does it require it. As Raustøl points out:

Even though I give some special weight to the good of my friend in my practical deliberation, I am only justified in doing so if I can defend the rule upon which I am acting against the requirement that this rule, if widely accepted, would tend to give equal importance to the good of each. In this way, argues the indirect impartialist, the agent can care about the other for his own sake, and still respect impartiality.

(Raustøl, 2010, p. 35)

Another way of putting this is to say that if I (as a nurse) think I am right in giving special attention to one of the patients I am responsible for, I must accept that any other nurse also is right in giving special attention to one of her patients. But note that this right, if accepted, is a right of nurses, not of patients. In that case we should say that if I (as a patient) think I have the right to special attention, then I must accept that any other patient also has this right. Theoretically, such rights can be impartially justified both from Hooker’s account and from Barry’s account. The problem is how to deal with the practical implications, especially situations of scarce resources. This is not a problem exclusively for impartialists, though.

As we have seen, moral impartiality can be comprehended on three levels. The rest of this chapter consists of an analysis of the notion of partiality.

The notion of partiality

Partial acts and partial standings

In the ethics literature, partiality is generally understood as special attentiveness, responsiveness, and favouritism between or among those who are considered to be close (Friedman, 1991, p. 818).⁸ Scheffler, for instance, argues that par...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• Introduction
• 1. Partiality and impartiality in nursing care
• 2. Partiality and professional ethics in nursing care
• 3. On the concept of need for nursing care
• 4. Care ethics, partiality, and interpersonal relationships
• 5. Towards a prerogative for partiality in nursing care
• 6. Partiality, justice, and moral dilemmas
• 7. Towards an ethics of nursing care
• Index