Pym Scott

This article discusses nurses’ and elderly patients’ perceptions of the realization of autonomy, privacy and informed consent in five European countries. Comparisons between the concepts and the countries indicated that both nurses and patients gave the highest ratings to privacy and the lowest to informed consent. There were differences between countries. According to the patient data, autonomy is best realized in Spain, privacy in the UK (Scotland), and informed consent in Finland. For the staff data, the best results tended to concentrate in the UK. The conceptual and methodological limitations of the study are identified and discussed. Implications of the results are divided into three areas: nursing practice, education and research. In practice, the analysis of patients’ values and the ethical sensitivity of nurses are important as part of ethically good care. In nurse education, students should learn to recognize ethical problems, generally and particularly, among vulnerable groups of patients. Multicultural international research is needed in this area. This is the last of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented

Diagnostic self-testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point-of-care facilities and at home. Designed to allow earlier detection of diseases, self-testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve health and reduce health costs. However, the full implications of future home-based diagnostic technology for individuals and society remain unclear due to their novelty. We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home-based self-testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation. While the ethical issues are not necessarily new, the development of home-based self-testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities.

The Lourdes Hospital Inquiry: An inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda, Ireland, of 2006 recounts in detail the circumstances within which 188 peripartum hysterectomies were carried out at the hospital between 1974 and 1998. The findings of the inquiry have serious ramifications for Irish healthcare delivery and have implications for many professional groups, including midwives. The findings prompt clear questions about the relative position or power of midwives within maternity care. These questions are examined in this article, through the analysis and application of various theoretical perspectives on power. Critical views of power focus on the socio‐political nature of oppressive structures within society and seek mechanisms to address these. Stemming from structure versus agency debates, Giddens's structuration theory examines the agency‐structure interaction and stresses the centrality of agents’ roles in the social reproduction of structures. Postmodernism, particularly drawing on the work of Michel Foucault, focuses on a fluid conception of power while also describing the nature of disciplinary power. It offers midwives a way of viewing power as productive and dispersed. Drawing on different aspects of these perspectives on power, helps us to understand midwives’ relative positions and power relations and how to enhance these to prevent future tragic outcomes such as those reported in the inquiry report.

Background: Moral courage is defined as courage to act according to one’s own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses’ career. Aim: To analyse graduating nursing students’ moral courage and the factors associated with it in six European countries. Research design: A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with a single question (visual analogue scale 0–100), the questionnaire also covered several background variables. Participants and research context: The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students’ moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires. Ethical considerations: Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent. Results: The mean of graduating nursing students’ self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0–100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students’ moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves. Discussion and conclusions: In all countries, the graduating nursing students’ moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research.

Modes of rationality in nursing documentation: biology, biography, and the ‘voice of nursing’ This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text‐based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jürgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio‐centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self‐determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio‐technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent — the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice.

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility

Current focus in the health care ethics literature on the character of the practitioner has a reputable pedigree. Rather than offer a staple diet of Aristotelian ethics in the undergraduate curricula, perhaps instead one should follow Murdoch's suggestion and help the practitioner to develop vision and moral imagination, because this has a practical rather than a theoretical aim. The imaginative capacity of the practitioner plays an important part in both the quality of the nurse's role enactment and the moral strategies which the nurse uses. It also plays a central part in the practitioner's ability to communicate with a patient and in the type of person which the practitioner becomes. Can the moral imagination be stimulated and nurtured? Some philosophers and literary critics argue that not only is this possible, but that literature is the means of doing so. If this is the case then a place should be made for literature in already crowded health care curricula