Commentary: Ethical Conflicts or Political Problems in Intrapartum Nursing Care?

The findings of Sleutel's paper are disturbing at best. I share with her the hope that the ethical issues she has identified involve only isolated incidents, but I fear that the abuse of power in nurse-physician relationships is still all too common. The most important issue, however, is not to determine how frequently this problem occurs, but to address the source of the problem. I believe it is the systemic power of medicine that enables some physicians and nurses, and I underscore “some,” to engage in the type of ethically questionable care that Sleutel describes. I shall address this issue in several ways: first, I clarify the meaning of ethical dilemmas; second, I describe the complex nature of medical power and how it can lead to poor relationships among nurses and physicians and the devaluing of nursing knowledge and clinical judgment; and third, I offer some potential solutions. Sleutel has entitled Theme 2 in her data as “Ethical Dilemmas: An Unwilling Partnership.” Beauchamp and Childress ( 1) describe moral dilemmas in the following way: “In a moral dilemma, an agent morally ought to do X and morally ought to do Y, but the agent is precluded by circumstances from doing both. In a dilemma, the reasons behind alternatives X and Y are weighty, and neither set of reasons is obviously dominant” ( 1, p4). The statements Sleutel describes do not suggest moral dilemmas. Being an unwilling partner in care that is focused, not on the patient's best interests, but on the physician's, does not have the elements of a moral dilemma. I think all health care professionals can agree that the common and ultimate good of our practice is patient well-being. This good morally justifies our values and actions. The need of physicians to have deliveries completed within their clinic times and the need of nurses to make physicians happy do not generally coincide with the needs of patients and, hence, their well-being. Therefore, there is no morally good reason to support being an unwilling partner. Thus, there is no moral dilemma, just ethically substandard care. I do not fault Sleutel with her choice of words. Health care ethics has almost exclusively focused on ethical dilemmas, leaving the many everyday ethical concerns unaddressed. Many of these fall into what I call the moral minimum. It is care that is far from the ethical ideal, but is not extreme enough to be reportable, such as clear-cut incidents of patient abuse. One reason why, I believe, the moral minimum is infrequently spoken about is that likely all of us, as health care professionals, have engaged in or have witnessed some form of morally minimum care. Perhaps it is our moral culpability or our sense of powerlessness that prevents us from speaking and acting on these types of issues. The words “unwilling partnership” suggest that the feeling of powerlessness perhaps is the reason that the nurse in Sleutel's study participated in morally minimum care and seems to have only spoken about it under the protection of anonymity. Her behavior speaks of the inextricable connection between ethics and politics in nursing. The situational constraints that nurses face when they attempt to behave morally in a health care system in which they have little power has been widely commented on ( 2-11). The powerlessness experienced in this case arises through the nurse's partnership with particular physicians—a powerlessness that has complex origins. No doubt, one aspect of this power difference stems from medical and nursing roles mirroring traditional gender roles of male dominance and female subservience. In addition, however, the dominance of medicine in North America is supported through powerful institutional alliances with the state, legal, and education institutions, funding agencies, pharmaceutical industries, and heath care businesses. The biomedical model is so entrenched it is often viewed as the only credible paradigm in these institutions as well as in clinical and research settings ( 12). The underlying power of medicine is evident in the questions Sleutel poses when she considers the practice implications of her research. She asks whether nurses have the right or responsibility to refuse to administer oxytocin when no medical indications are present. Again, there is no ethical dilemma here. If patient well-being is being compromised, the nurse has the moral responsibility to refuse to administer the drug and should be given the institutional/societal right and protection to do so without sanction. Sleutel also asks how nurses can meet the interests of both patients and physicians when their interests collide. Again, the nurse's and the physician's primary concern should be with the patient. Nurses do not need to meet the interests of physicians, beyond a reasonable level of professional responsibility and concern. The power of medicine has led not only to Sleutel's “unwilling partnerships,” but also to “nurse-physician conflict” (Theme 3). Although written over 30 years ago, the types of nurse-physician interactions described are reminiscent of Stein's depiction of “The “Doctor-Nurse Game” ( 13). He describes a form of interaction whereby nurse and physician communicate in a fashion that avoids open disagreement and allows the nurse to give recommendations and the physician to request recommendations without appearing to do so. In this way, the power of the physician is not threatened and the subservience of the nurse maintained. Similarly, Sleutel's data show how a nurse used strategies to deal with physicians, such as letting them “not feel threatened,”“feel like they are in control,” and that she is “the subservient one.” The need to avoid open disagreement is also evident by the nurse's statements that, for example, she is “tactful,” that she tries “to keep good working rapport with the doctors,” and that she is “NOT going to argue with him in front of a patient.” This form of game playing is morally problematic because it does not foster the open dialogue needed to provide quality patient care. Nurses need to have conviction in their power to make a difference in care, and need to take responsibility for their judgments and actions. Continuing to play the doctor-nurse game can lead to what Rubin ( 14) calls “delegating up”—a process whereby nurses avoid ethical decision making by invoking the authority of physicians as the basis for their decision making. Sleutel also states that the culmination of competing viewpoints, philosophies, and beliefs of nurses and physicians resulted in “nurse-physician conflict.” These differences, however, are not simply ideological. They also reflect the hegemony of medical knowledge. It is not surprising that the nurse in this study stated that in her experience “many of the physicians don't care what the nurses have to say.” The knowledge and skill of nurses have been described as invisible ( 15-17). This invisibility fosters a lack of appreciation of nursing knowledge by physicians and others, including nurses themselves. This problem underscores the importance of studies like that of Sleutel, which uncover the knowledge embedded in nursing practice. Her study reveals the complexity and importance of nursing interventions that support laboring women. Without these interventions cesarean births may be more common and patient wishes for greater control over the birthing process may not be honored. When nursing expertise is devalued and is not realized in clinical practice, the quality of patient care may be compromised, creating a significant ethical concern. Where do we go from here? For the most part, solutions to the ethical problems discussed are political in nature. They are complex, far-reaching, and not easily achieved. First, health care professionals and the public need open awareness, acknowledgment, and discussion of these types of ethical and political problems. Consciousness-raising may be the first step in making change. Second, institutional mechanisms need to be put into place that assist nurses and physicians in conflict resolution and team building. Third, with respect to nursing specifically, many nurses need to increase their unity, assertiveness, and clinical expertise so as to stop participating in the “doctor-nurse game.” Professional accountability and a belief in one's clinical and ethical decision-making capacity are required to enhance ethical agency. Fourth, nursing must continue to uncover and communicate nursing knowledge and expertise through further research and education. In this way, the practice of nursing has the potential to become visible and valued. Fifth, and most important and challenging, widespread professional and public resistance to the power of medicine is required—a power that can help fuel these incidents of unethical practice in the first place.

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