Ethics and values in health care practice: philosophical, educational, and political considerations

Abstracts

Tratam-se de considerações filosóficas, pedagógicas e políticas sobre Ética e Valores na Prática Profissional em Saúde. O tema refere-se às mudanças do mundo de hoje, demarcadas por crises econômicas, com questões de justiça social afetando saúde e educação. Objetiva-se clarear a função de enfermeiras/os em âmbito da arte assistencial de cuidar de clientes, em programas de saúde individual e coletiva; exortar enfermeiras/os à atenção às leis e códigos da profissão; sugerir a aplicação de leis básicas da Filosofia da Arte aos cuidados de enfermagem. Análise e crítica de ações profissionais implicadas em ética e valores afetando a arte de aprender-a-ser e de tornar-se profissional proficiente na função de cuidar em enfermagem. A posição da autora tem pertinência epistemológica face ao Saber/Conhecimento de Enfermagem e à resolução de situações de risco a ver com competências de poder-fazer as coisas ou de produzí-las em âmbito de enfermagem como ciência da saúde.

Saúde pública; Enfermagem; Arte; Ética em enfermagem; Valores sociais; Prática profissional

REFLECTION

Ethics and values in health care practice: philosophical, educational, and political considerations^*

Ética y valores en la práctica profesional en salud: consideraciones filosóficas, pedagógicas y políticas

Vilma de Carvalho

PhD in Nursing. Full Professor in Public Health Nursing, Escola de Enfermagem Anna Nery, Federal University of Rio de Janeiro. Head of the Group for Nursing Research and Epistemological Studies, Federal University of Rio de Janeiro/CNPq. Rio de Janeiro, RJ, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

This paper presents philosophical, pedagogical and political considerations on Ethics and Values in Professional Health Care Practice. The current changes and crises in the world, intensified by economic turmoil, have affected social justice issues affecting health and education. Objectives: to clarify nurses' role in the context of the art to take care of clients both as individuals and community; to urge nurses for attention to laws and codes/norms as established in the profession; and to suggest the application of basic laws of the Philosophy of Art to nursing care. The study presents critical analysis on ethics and values involved in nursing actions and may affect the art of learning-to-be and becoming an expert professional in nursing care. The author's epistemological position is presented to build competencies in the nursing as a health science.

Descriptors: Public health; Nursing; Art; Ethics, nursing; Social values; Professional practice

RESUMEN

Consideraciones filosóficas, pedagógicas y políticas sobre Ética y Valores en la Práctica Profesional en Salud. El tema refiere los cambios del mundo actual, marcados por crisis económicas, con cuestiones de justicia social afectando salud y educación. Se objetiva aclarar la función de enfermeros/as en ámbito del arte asistencial de cuidar de pacientes, en programas de salud individual y colectiva; exhortar enfermeras/os a atender leyes y códigos profesionales; sugerir la aplicación de leyes básicas de Filosofía del Arte a la atención de enfermería. Análisis y crítica de acciones profesionales implicadas en ética y valores afectando el arte de aprender-a-ser y de convertirse en profesional proficiente en la función de cuidar en enfermería. La posición de la autora tiene sustento epistemológico frente al Saber/Conocimiento de Enfermería y la resolución de situaciones de riesgo relativas a la competencia de poder-hacer las cosas o producirlas en el ámbito de enfermería como ciencia de salud.

Descriptores: Salud pública; Enfermería; Arte; Ética en enfermería; Valores sociales; Práctica profesional

INTRODUCTION

There is general consensus that the world today is in transition and overwhelmed with crises. Difficulties emerge from the answers to general wellbeing. No longer are there expectations for better life and work conditions. It has not been long that through wisdom we could adjust the distortions of social justice. There is no barrier for scientific-technological advancement, but as far as human dignity is concerned, everything appears to be more precarious. The wealth of few and the poverty of many continue to rise. New social classes emerge on the tables of foreign and domestic debt, bank applications and devaluations. The economic policy now generates generalized impoverishment – at the peak of global crises – affecting every country. Meanwhile, public protests – youths, workers, and other movements, such as against violence – have claimed law measures and political order in most nations.

The affected areas involve the health for all and education for all. In professional health practice, no profession is free from or capable of escaping the turbulence and changes. In Nursing, the acute issue is knowing and justifying the essential ethical and legal principles of the role to take care of clients. Because not even the basic principles support the knowledge and the meaning of saying that something is technically correct and just. Or – on the other hand – if it is possible to assume the position of stating if the professional what-to-do counterbalances with pure negligence and no ethical justification.

Ethics is a branch of Philosophy that results in Moral Philosophy or the philosophical thinking about morality, moral issues, and moral judgments. Norms and notions about morality address emerging attitudes and behaviors in the decisions about problems that could be solved in a regular traditional or legally established way.

This form is opposite the analytical or critical thinking that, in an epistemological sense, is appropriate to the empirical or historical investigations that do not involve any defense of normative judgments or judgments of value⁽¹⁾.

Through Nursing, I see myself as driven by an analytical and critical thinking restlessness. I seek an explanation to teach and investigate problems with the plan to produce knowledge. But I feel perplex in face of the issues associated with ethics and human values – the nurses' what-to-do regarding the dignity of the profession, which is universally accepted according to Nightingale's⁽²⁾ concept of nursing care practice to promote and take care of clients, including their relatives. A practice in the art of nurses is revealed in the role of taking care of clients, through the continuing educational refinement tending towards scientific and technological innovations. According to the Parsonian⁽³⁾ approach, social practice aiming at the prevention and promotion of health and treating health unbalances. Therefore, nurses' competencies and responsibilities cooperate with the sanitation guidelines and help to restore health, and contribute specifically with the professional health practice.

In this practice, it is the duty of nursing professionals to justify the nursing diagnoses, defend their interventions and provide help to human groups. According to the Professional Laws and Codes^(4-5), the what-to-do in technical and ethical procedures is relevant for the conducts and behaviors along with nursing care. A maximum attention on the premises and foundation About Nursing– Teaching and Professional Profile⁽⁶⁾, without losing

the essence of performance – the nursing art of care–, and assign security and quality to actions and operations of the actors regarding their style of acting, demonstrated through examples, and interpret their own expression of art in the role of taking care within the domain of social practice⁽⁷⁾.

Regarding Ethics and Values in Professional Health Practice, I address the philosophical, pedagogical and political considerations. I am interested in the implications for Nursing. I can register, herein, what is specifically pertinent to the meaning of the role of nurses, in the art processed in the care to clients^(4-5). What I know is little. I listen in the classrooms, during investigative activities, and when producing science. There are changes in the health care programs and facilities. Through the role of caring, the reports present misfits and risks which compromises the assistants and assisted. I am concerned with the essence of the art professed – substantiated in acts and operations of the art of nurses^(2-3) and adjectivized in the care to clients in the health area.

At the 16º SENPE⁽⁷⁾, I addressed this art allied to the basic laws of the Philosophy of Art⁽⁸⁾, precious laws in the evaluation of the professional actions and a demonstration of the utility of nursing care; in fact, the professionals pay attention to the health policies and practices⁽⁹⁾, but, above all, it is imperative that the care art is consistent with the fundamental idea of nursing triangulated by the words art-science-ideal⁽¹⁰⁾. There is a need for attention to the pertinence of decisions and actions in the practice of the role of caring, in the care to clients and in the signification of The Art of Nursing – ephemerons, gracious, and perennial⁽¹¹⁾. More emphasis is needed on the importance of the competences of nursing, in the professional health practice, regardless of the management and administrative diversity, whether it is institutionalized or not. For the health in the world and in Brazil, I perceive the art of nurses according to the proposal about Public Health Nursing as a Social Practice⁽¹²⁾, constituted for the needs of human groups, considering all the assisted and assistants and, naturally, related to the undergraduate education and the development of nurses' professional profile.

A HISTORICAL POINT

Considering the Brazilian Nursing, and referring to the transposition of the Nightingale Modern Nursing System⁽¹³⁾, the system of nurses' professional and educational model dates of the Parsons Mission 1922-1931⁽³⁾. Much has changed. However, when completing that Mission, the system of the model was presented – legally and ethically– as norms of the education and health care policy, according to Decree number 20,109/31 (first Law of Nursing Practice), and all the rest resulted in nurses' attributions and responsibilities in the professional health practice. The further battles and landmarks of the Brazilian Nursing are stated in the annals of the Brazilian Nursing Association (Associação Brasileira de Enfermagem – ABEn)⁽¹⁴⁾.

The current norms by the Professional Legislation^(4-5) are advanced for the role of nurses, as long as the legal bases and distinctions regarding the nurses' what-do, know-do and also can-do, thus, in agreement with the issues of ethics and values⁽⁷⁾. Regarding the historical advancements, the basic scientific principles of Nursing⁽¹⁵⁾ are universally considered in the professional performance in the education and health care areas.

Without addressing details regarding the Carlos Chagas Reform (1920's), the issues of professional health practice, concerning Nursing practice, have been affected with adverse questions – insufficient human and material resources and structural deficiencies–, interfering in the role of nurses. Serious misfits are common. Even the new educational acquisitions and the new normative dispositions^(4;5) do not assure advancements in health policies, and –in real situations– multidisciplinary conflicts still persist in the professional health practice. This harms nurses' identity, particularly because of the negative ideology in face of the professional autonomy in thinking and acting, in the interventions and decisions about the care to clients.

Regarding Nursing, this fact does not refer to a simple refusal of the power that is delegable or delegated by the medical profession. However, considering the 1980 Health Reform and the implementation of the National Health System (Sistema Único de Saúde -SUS), the role of caring, in Nursing, and the care provided with autonomy, management and responsibility still suffer the harms of prejudice and pressure from conflicts that achieve the interdisciplinary relationship⁽¹²⁾. This issue requires further investigation. The premises and objectives of the health for all and the noted duty of the State do not make visible the intended changes of universalization and solvability of health care. For this reason, the professional health practice now lays in a collection of measures, sometimes, unfeasible and supposedly aiming at health with equity for all and, most of all, as a citizen's right.

A BRIEF DESCRIPTION OF THE HEALTH SCENARIO TODAY

In the SUS, the environment of health professions now appears to be diversified. Not in the large hospital and health centers, but in the newly-named innovative programs. In the State of Rio de Janeiro (RJ), for instance, with similar tendencies across the country, there are Family Clinics and Community Care Centers, Emergency Care Units, and the Family Health Strategy. The new services provide accessibility to the large institutions, with faster care to the population. They provide from emergency care and medical treatments to basic nursing care^(16-17). They aim at primary health care and the follow-up of collective groups. Programs exist for: the elderly, individuals who are confirmed or suspected to be HIV-positive, individuals addicted to drugs, women in the prenatal period, care to children and adolescents, cancer patients, groups with special needs. In addition, there are outreach programs at hospital institutions or universities, namely for communities, with health care or education purposes^(16-17). Nevertheless, the programs are below the demands of the population.

These programs are relevant, though there is insufficient information about the assessment of the assistance, the outcomes or epidemiological data regarding the effectiveness of the available programs⁽¹²⁾. Despite lacking total control, the reliability in solution measures and treatments for health care problems address the nurses' what-to-do, know-do, and can-do in individual and collective health⁽⁷⁾. In Nursing – considering assistants and assisted – these programs address the difficulties of teamwork – specific and multidisciplinary – with the problems of management and administration, coordination and leadership of innovative health care models, without disregarding the conflicts of interdisciplinary participation and contribution in the professional health practice.

AN EPISTEMOLOGICAL COMPLICATION

Regarding the can-do, although the knowledge domain of superior level professions is legally established, in the case of Nursing, nurses (working as a team), sometimes face unclear obstacles. Some typically ideological obstacles designate the role of nurses as a supposedly subaltern occupation⁽¹⁸⁾. Without any agreement, the role is associated with the medical power (delegated or delegable?) and, thus, disregarding the epistemological pertinence of the professional Nursing knowledge. There is an implied urgency for empirical studies of the art of Nursing care: experiences that confirm the evidence, controlled performance assessments, repetition exams, or for the topological framework with geometricized representations or demonstration of mathematized practices⁽¹⁹⁾. These studies should justify the coherence of Nursing care and the pertinence of ethics and values that reveal the requisitions of a scientific practice of social utility⁽¹²⁾. They are obstacles that generate epistemological⁽²⁰⁾ conflicts that interfere on the development of the professional ethos and nurses' critical attitude.

In the pedagogical practice, the obstacles harm the role of nursing care. In the media, obstacles emerge as misunderstandings and affect the reliability in education, raising the connotation of professional subsidiary^(12,18). This cannot be accepted. The national curriculum guidelines about Nursing Undergraduate studies speaks for itself⁽²¹⁾. It the professional education is not correctly processed, which harms to professional practice, the role of nursing care is also harmed, despite already being established in the foundations of the profession^(2,15). The drawbacks involve the knowledge of the profession, the legitimacy of the practice in management and administration, and the nurse leadership⁽²²⁾. It is a matter that must be solved, because it surpasses the professional differences in the multidisciplinary or interdisciplinary relationships, in the health care system. Because of its epistemological character, an unintended position cannot be assumed.

The stricto sensu Graduation Program – according to the II PBDCT 1974⁽²³⁾ –, already in existence for over three decades, assures Nursing the visibility among the health professions. Regarding Nursing, the pedagogic practice and knowledge refer to investigations from scientific initiation (undergraduate studies) until the development of dissertations and theses (graduate studies). They also refer to mastering the art of caring and the intellectual ability to solve problems and dilemmas of professional practice⁽²⁴⁾. A firm attitude is required regarding the adequacy of can-do things or produce them⁽²⁰⁾, in the investigation or in the expressiveness of healthcare art. In professional health practice, health care must be critical and the Nursing profession can only be understood as health science.

In the enjoyment of mastering the art of Nursing,

one cannot admit inadequacies in the demonstration through the example, in the sense of the artistic expression, nor in the ethical value of the vocational mystic⁽¹³⁾.

Interests and objectives should not be minimized when considered relevant for the social importance of nursing care. In the professional health practice, in any work domain, as well as the pedagogical practice, appropriate to form the professional profile, students must learn attitudes and behaviors that surpass the technical aspect. Without ruling out the disciplinary contents and experiences of ethics and human values, we must help and encourage students to work with clients in the health programs and plans at the individual and collective levels. In the experiences of learn-to-be and of becoming a competent professional, students must acquire valuable skills and ethical behaviors of unquestionable importance for the social accountability of nurse professionals.

Students must learn, from a critical perspective, the requirements and foundations of the art of Nursing⁽¹¹⁾. An expressive art for the clients, and that, at a theoretical level, can implement the background knowledge of the profession as an epistemological axis of health care. Furthermore, they will need to understand about the current situation of the health area, in which difficulties regarding the role of Nursing care persist. This is a problematic issue, filled with ambivalences and contrasts. Because, if on the one hand the clients' situations invoke Nursing care needs, sometimes, due to adverse conditions they can cause misfits in the art of health care regarding the citizen rights of the clients and their guardians. On the other hand, one cannot deny the opportunities of experiencing the art of caring in the settings of professional health practice, in the so-called programs of the SUS system.

Although on the opposite direction, much can be learned, not only from the rights but from wrongs as well. All it takes it to focus on the primary purpose of the Nursing profession, as the art of teaching, caring and investigating. Wonderful! Considering that professional practice and the experience with the health staff can promote learning and the improvement of the form to express the art of caring. Meaningful art emphasized in view of the clients' needs, because it invokes assess the effects of Nursing care, and, thus, regarding the premises of the art that is professed. In spite of the evolutional leaps and the almost secular walk about the Professional Knowledge in Nursing⁽²⁵⁾ students must learn that there serious difficulties still persist regarding the role of caring, namely when it is understood as a social role and specifically assumed as a professional art.

FINAL CONSIDERATIONS

According to the philosophers of art ⁽⁸⁾,

for the strategy of learning-to-be competent and becoming an artist and exemplary interpreter in the expression of art, it is necessary to accentuate, in the scenic experiences of acting, the meanings of art in the role of the artist, and in the context of the requirements of the social environment (this is the issue regarding the essence of art).

All the practitioners involved must consider, in the role of the artist and, particularly, in the social environment, that what is actually important is what is done or produced in the art environment itself (and this is the 1^stLaw of Art, as a function of the environment).

The philosophers point out two other laws to appreciate and justify the expressions of art, the 2^ndLay of the Art of Idealism (or law of the continuing process). Through this law, art depends on continuing education and as a permanent process it agrees with the idealism of art (the obstacles emerge due to the artists' lack of educational refinement).

The 3^rdLaw of the Art of Spirituality (or the law of involving subjectivity in spirituality, referred to as the law of growing dematerialization). For the artist, it is important to evolve intellectually and in sensitivity – spiritually –, and this agrees with the increasing dematerialization. In other words, mastering the what-do, think-know and can-do surpasses material plans to plans of pure intelligibility and spirituality (the obstacles refer to the misfits in art, or occur due to a delay in mastering the professional knowledge). The action of nurses must improve at a maximum carat in the art of health care. Contradictions occur because of negligence or omission, which can thus cause occupational risks in the role of caring, or when actions and operations are not effective, expressing criteria of quantity and requirements of quality in the care provided to clients. Failures are a serious issue. It is necessary to assume a firm professional attitude of correctness and defending the art of nurses in the professional health practice. The basic laws of the Philosophy of Art⁽⁸⁾, therefore, can help in education and must be applied in the institutionalized experiences and in the open social environment. Without their support (I believe), it is not possible to defend the cause of Nursing.

I am unable to point at other paths for the issues regar-ding Ethics and Values in the Professional Health Practice. I believe: rethinking Nursing teaching and learning is urgent. It is important that ethics and values also meet the substantiality and the causality of issues that claim to be verified by nursing science. Regarding the health care justifications and the investigative questions about nurses, the evaluation of the care subscribes unequivocal foundations for Nursing care. I think with the faith of the profession: it is impossible to not include or ally these three laws⁽⁸⁾ to the pedagogical strategies in Nursing Education.

Last, but not finally, may I defend the Nursing profession, as I believe it to be structured, essentially, on the art of love for your neighbor – all of which include assistants and assis-ted. Furthermore, I see it is a profession guided by a Christian premise, fundamentally rooted in by nurse spirit:

It is not enough to believe in things; you must love them.

And love is much more than believing.

(Imitation of Christ)

REFERENCES

Received: 10/14/2011

Approved: 11/16/2011

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Correspondence addressed to:

Vilma de Carvalho

Rua Afonso Cavalcanti, 275 – Cidade Nova

CEP 20211-110 – Rio de Janeiro, RJ, Brazil

*

Study presented at the Round Table "Desafios Contemporâneos da Saúde Coletiva", 2º Simpósio Internacional de Políticas e Práticas em Saúde Coletiva na Perspectiva da Enfermagem – SINPESC, School of Nursing, University of São Paulo, São Paulo, Oct. 9th -11th , 2011.

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Received
  14 Oct 2011
• Accepted
  16 Nov 2011