Judith Andre

As feminist theory explicates its fundamental principles – justice for the oppressed – it can lose its essential focus on the situation of women. One example is the inattention to nurses within feminist bioethics. Nurses deserve attention because most are women, but also because their lack of power is paradigmatic of patriarchy. Those examining ethics consultations should discuss whether nurses are allowed to request them. But feminists also need to imagine ways in which nurses can be heard when, for instance, their worklives are “redesigned.” Doing so would also allow attention to other classes of the disempowered.

The aim of this study was to explore the existence of moral distress among nurses in Lilongwe District of Malawi. Qualitative research was conducted in selected health institutions of Lilongwe District in Malawi to assess knowledge and causes of moral distress among nurses and coping mechanisms and sources of support that are used by morally distressed nurses. Data were collected from a purposive sample of 20 nurses through in-depth interviews using a semi-structured interview guide. Thematic analysis of qualitative data was used. The results show that nurses, irrespective of age, work experience and tribe, experienced moral distress related to patient/nursing care. The major distressing factors were inadequate resources and lack of respect from patients, guardians, peers and bosses. Nurses desire teamwork and ethics committees in their health institutions as a means of controlling and preventing moral distress. There is a need for creation of awareness for nurses to recognize and manage moral distress, thus optimizing their ability to provide quality and uncompromised nursing care

Hope as a virtue is an acquired disposition, shaped by reflection; as a civic virtue it must serve the good of the community. Ernst Bloch and Lord Buddha offer help in constructing such a virtue. Using a taxonomy developed by Darren Webb I distinguish open hope from goal-oriented hope, and use each thinker to develop the former. Bloch and Buddha are very different (and notoriously obscure; I do not attempt an exegesis). But they share a metaphysics of change, foundational for making any sense of hope.Buddhism would seem to repudiate hope; it is a source of suffering (i.e., pain in living with reality). Seen more deeply, however, Buddhism offers material for a carefully limited virtue of hope: the habits of noticing good and acknowledging transience. This disposition, acquired through Buddhist practice among other ways, shields one against despair. The habit also frees up energy that would otherwise be wasted. Ernst Bloch gives us insight into how to use that energy, teaching us to value the yearning implicit throughout culture. Open hope becomes a civic virtue when it concerns civic matters; it can be threatened by hyperbolic discourse in political life.

During medical training students and residents reconstruct their view of the world. Patients become bodies; both the faults and the virtues of the medical profession become exaggerated. This reconstruction has moral relevance: it is in part a moral blindness. The pain of medical training, together with its narrowness, contributes substantially to these faulty reconstructions. Possible improvements include teaching more social science, selecting chief residents and faculty for their attitudes, helping students acquire communication skills, and helping them deal with their own pain. Most importantly, clearer moral vision requires time and scope for reflection.

Self-regarding acts are frequently classified as non-moral; even more frequently, they are assumed to have less moral weight than parallel other-regarding acts. I argue briefly against the first claim, and at greater length against the second. Our intuitions about the lesser moral weight of self-regarding acts arise from imperfectly recognized, and morally relevant, differences between acts which are ordinarily described in misleadingly parallel phrases. ‘Love of self,’ for instance, and ‘love of another’ are not symmetrical attitudes, in spite of the symmetrical grammar. More obviously, one cannot steal from, lie to, nor force oneself in the same way one can do these things to others. I conclude, therefore, that difference in moral weight never stems merely from a difference in the person concerned, but rather from differences between the actions themselves; furthermore, that whatever it is wrong to do to a willing other, it is wrong to do to oneself.

Knowledge of others, then, has value; so does immunity from being known. The ability to extend one's knowledge has value; so does the ability to limit other's knowledge of oneself. I have claimed that no interest can count as a right unless it clearly outweighs opposing interests whose presence is logically entailed. I see no way to establish that my interest in not being known, simply as such, outweighs your desire to know about me. I acknowledge the intuitive attractiveness of such a position; but my earlier discussion concluded that the value of privacy is ease, and the value of knowledge is understanding - and it's not obvious that either outweighs the other. Nor is it obvious that the freedom and autonomy which result from the power to limit what others know is more significant than the freedom and autonomy which result from the power to extend one's knowledge. I believe the intuitive attractiveness of the belief that privacy values outweigh knowledge values lies in the entirely correct belief that a society without any privacy would be unpleasant. But a society without mutual knowledge would be impossible.I conclude therefore that there is no right to privacy nor to control over it. Nevertheless, each of these things is a good, and a good made possible (given the presence of other people) by social structures. A desirable society will provide both privacy and control over privacy to some extent. Nothing in my analysis helps determine what the proper extent is, nor what areas of life particularly deserve protection. Those who would argue that privacy and control over it are entailed by respect for persons should, I think, choose instead some particular areas central to being a person, to counting as a person, and then show how one is less likely to exercise one's capacities there fully without privacy or without control over it. Although Gerstein's attempt fails because he inaccurately defines intimacy as a kind of absorption and incorrectly opposes absorption with publicity, I think it is the kind of attempt which must be made. Furthermore, he has probably chosen the right area of life - if anything has a special claim to privacy it is probably the union between people who care for one another. The value of being together alone may be more significant than the value of being alone, if only because words and actions are public while thoughts are not. But I will not try to develop that argument here.In any case both privacy and control over it are social goods; on egalitarian grounds they should, ceteris paribus, be equally available to everyone. This helps explain the “dehumanizing” effect of institutions which provide no privacy at all- prisons and some mental institutions. It is not so much that the inmates are totally known; it is rather that those who know them are not so fully known by them; further, that the staff has a great deal of control over what they disclose of themselves, and the inmates very little. The asymmetry of knowledge in those institutions is one aspect of the asymmetry of power; the completely powerless are likely to feel dehumanized.My analysis also helps account for the wrongness of covert observation. It is not simply that the observer violates the wishes of the observed, for the question is whose wishes trump. The observer is violating the justified expectations of the observed: expectations supported by weighty social conventions. These have more moral weight than simple desires do. The peeping torn is violating a convention which structures the distribution of knowledge, a convention from which he benefits. Without it his own activities might well be impossible. He might be more easily caught; or his victim, less trusting, might choose houses without windows. More deeply, the thrill of what he is doing depends on the existence of the convention. Even morally permissible excitement - the suggestiveness of some clothing- would disappear without conventions about nudity. Presumably, too, there are elements of his own personal life for which he values his privacy. He is on grounds of justice obligated to observe the rule which makes his benefits possible.(Some claims to privacy result from personal predilections, rather than from convention. Parent describes a person who is extremely sensitive about being short, for instance, and does not want his exact height to be common knowledge. Parent, p. 346. The grounds for these claims are obviously different from those I've been discussing. The grounds are the moral obligation not to cause needless pain, or, if the information was given in confidence, to keep one's promises.) Although there is no right to privacy or to control over it as such, there is a right to equality of consideration and to a just distribution of benefits and burdens. To put it another way: there is no natural human right to privacy or to control over it; but a good society will provide some of each, and justice requires that the rules of a good society be observed. This paper was written during Joel Feinberg's 1984 NEH Summer Seminar. I am indebted to NEH for funding, and to Professor Feinberg and the other members of the seminar for helpful comments.