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

Andre, Judith

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8	Andre p.   Remember the NursesFeminism used to be about women.  Feminist activists set out to improve the situation of women; theorists set out to to understand it. Those basic commitments still hold, of course, but as our understanding grew in sophistication, so did our commitments.  Sometimes I’m bemused by the present shape of feminism; as I write, for instance, the listserve for  FEAST (Feminist Ethics And Social Theory) hosts a passionate debate about whether “Duh!” is insulting to the cognitively disabled.  Susan Sherwin and Francoise Baylis’s article on feminist ethics consulting1 mentions women (separately from men) only rarely, and the only woman-specific issue they mention is contract pregnancy.  Knowledgeable readers, of course, recognize the authors’ fundamental principles as growing out of decades of work in feminist theory.  When the situation of women is well understood it is obvious that the same basic understandings apply to anyone living under oppression, and the practical commitment to work on behalf of women entails, morally, the same commitment to everyone similarly situated.  So FEAST members take seriously issues about the cognitively disabled, as they do issues about refugees, gays and lesbians, and others.  For the same reasons Sherwin and Baylis take issues of power (and its abuse) as central concerns for a feminist ethics consultant.These broader commitments, however, have paradoxical consequences and even dangers.  Sherwin and Baylis, for example, recommend that people invited to participate in a consultation should include the “health professionals with the most continuous, committed and trusting relationship with the patient.” (146) The authors do not make the obvious point that those health professionals are usually nurses. In general feminist bioethics pays relatively little attention to nurses, and I am sometimes puzzled as to why.  Roughly 95% of nurses are women, a proportion highly likely to continue.  Men generally avoid occupations identified as female, just as they generally avoid names and clothes thought of as belonging to women.  The taint of inferiority and contamination appears to be psychodynamically powerful.  When men do take up female-coded occupations, in my experience, they are likely to be impressive human beings, comfortable in their own identities, unthreatened by ordinary irrational fears.  But there is no reason to think that their attitudes will ever be the norm.Nursing has been an overwhelmingly female occupation for most of its history, and bears all the marks of that fact.  The field is idealized by the general public (“angels in white,” “the lady with the lamp”) but also understood simply as a handmaiden to medicine.  It is nurses that make a hospital into what it is, a place offering round the clock care.  Doctors diagnose and plan the management of disease, obviously essential activities, but the role of doctor does not include providing continuous observation and care.  A collection of doctors and their patients is a clinic, not a hospital.  Yet hospital administrators can ignore the input of nurses – highly skilled professionals – on how their own jobs are best managed.  This is a  standard gendered story: women seen as noble and warm hearted, their technical skills unnoticed and unhonored.  Work done by women receives at best sentimental appreciation; rarely is it genuinely respected. There’s another reason nurses deserve more attention from bioethics (and not just feminist bioethics): they are gatekeepers.  Again there are analogs everywhere: in poor countries where children are sick or starving, the best way to improve their situation is to help their mothers.  Mothers spend what aid they receive on children far more dependably than fathers do.  And so in health care: good patient care in hospitals depends on nurses.  A good nurse can often compensate for a poor physician; a good doctor cannot compensate for a poor nurse.  Something similar holds true in research: the protection of human subjects depends on the nurses to whom the protocol is entrusted. Let’s take it, then, that feminist bioethics should pay more attention to nurses.  How would such  attention figure into a feminist discussion of ethics consultation?   As Sherwin and Baylis point out, “ethics consultation” refers to a complex variety of activities; they themselves focus on two domains, the care of individual patients and input into public policy.  In what it omits this is a telling decision, about the commitments of philosophy and the reach of its tools.  As I argue in Bioethics as Practice, the tools of philosophy provide almost no insight, let alone practical guidance, into the moral character of organizations.  A philosopher myself, I was fortunate to have learned from social scientists something about hospital culture and policy.   (I want to emphasize, however, that this inadequacy in philosophy is not the result of unreflective individualism, contrary to the usual, itself unreflective, charge.)Ethics consultation at the level of patient care can be very useful to nurses.  Their occupational hazard is moral distress, defined in contrast to moral dilemmas: dilemmas are situations in which one does not know the right thing to do, while moral distress occurs when someone (believes that she) knows the right thing to do, but cannot do it.  Moral distress is a chronic experience in nursing, and typical of any work where responsibility exceeds authority – which is to say, much of women’s work.									Ethics consultation can be useful for nurses caught in such a bind, but the usefulness depends on several factors: nurses must have the authority to request consultations, and once convened they must have a chance to be heard.   A number of people, including Sherwin and Baylis, write usefully about ways to be sure that the disempowered have a voice around the table.  But few writers take up the question of who has the authority to request an ethics consultation.  There have been situations, for instance, where only physicians are allowed to call for a consult – no one else on the caregiving team, and no patient or family member.  Questions about why this happens, and what to do about it, belong to the neglected subjects of hospital culture and policy, which is to say to the fledgling arena of organizational ethics.  What I have learned from my own ventures into this arena is how very hard it is to work effectively in it.  Addressing this one element of policy – giving authority to nurses to request a consultation – could be done straightforwardly when a consultation service is first being set up.  Yet for hospitals with established consultation services which cannot be requested by nurses, resistance by medical staff can probably be assumed and would not easily be breached.  Doing so would require understanding not only what the formal chain of command is, but also the informal one, almost always the more effective.  Working effectively within it requires all sorts of different skills.  Most readers work within universities, and can understand by analogy what it is to work in other complex institutions.  But only by analogy; the specifics will be quite different, not only because of particular histories and personalities, but also because businesses are not at all democratic and job security does not exist.  Working to change hospital policy requires immersion and sensitive observation.  The work will reveal that the custom and culture of particular units is just as important as official policy.  Whatever official authority nurses possess, a  unit can be run in such a way that they cannot exercise that right.  (The same is true for dieticians, chaplains, social workers, and so on, also primarily female occupations.)So ethics consultations about the care of individual patients can be useful to nurses: the ability to request them and to be heard during them are levers of power, and by changing what is done, or changing the nurses’ understanding of what should be done, alleviate their moral distress.  Consultaltions also help resolve conflicts between doctors and nurses. Yet the moral distress of nurses occurs most often in areas beyond the purview of traditional consultation.  Far more than physicians, nurses work in teams and within institutions.  Decisions about the structure of their work have a major impact on nurses’ professional lives.  Bioethicists tend to know quite a bit about the moral distress faced by physicians, about the way, for instance, that  cost-containment interferes with a doctor’s ability to give patients appropriate care.  Nurses have experienced this same conflict for decades. The most recent surge arose from “patient-care redesign” during the 1990s.  Typically work that seemed to be menial, not requiring the expensive expertise of a nurse, was assigned to unskilled workers,  to housekeepers and orderlies.  Nurses could then be assigned more patients than they were before.  The new arrangement was thought to be a “win-win” solution: the hospital would save money, and housekeepers and orderlies would have more rewarding jobs.  (Previously they might have been ordered not even to speak to patients, much less to get them a glass of water.)   Nurses could spend their time on the technical jobs that only they could do.The trouble is that for the most part these ideas came from management, not from practicing nurses.  It was the old story of cognitive authority: nurses’ convictions about how their own jobs could best be done didn’t count.  Their resistance was dismissed:  “Nurses don’t like to change; they want to keep doing what they were trained to do.”  But in fact nurses change and change and keep on changing.  Their resistance was to workloads that were dangerously high, and to work being done by people not qualified to do it.  Changing a urine bag, for instance, seems purely menial.  But in fact noting the color of the urine is critical: if it is tea colored or blood-streaked, the patient is in trouble, trouble which if spotted early could prevent more serious complications.  Bathing a patient also seems menial, (and nurses stopped doing it long ago, for the usual reasons of cost containment).  But during a bath a skilled nurse was assessing the integrity of the patient’s skin, his degree of pain and mobility, and his mental status; she was also educating him about his changed body and supporting him emotionally as he adjusted to it.  Furthermore, this redesign of patient care put nurses in charge of less-skilled workers (the former housekeepers and orderlies).  Again the intention was good: more holistic care, more unity within a team of workers, and more flexibility.  Yet the one thing nurses have not trained in is supervising lower-skilled workers.  Not only were the new team members less skilled, they were unlicensed and (understandably) had less professional commitment.  Nurses are trained to do whatever needs to be done, however menial, if it is necessary for the welfare of the patient.  The emesis basin isn’t emptied?   Then the nurse does it.  She’s not just an employee, she’s a professional.  Creating a professional relationship with unlicensed personnel is a challenge.Spurred by stories such as these, David Kallen and I have done qualitative research into the issue.  We identified three major categories of moral distress: (1) The first, and the heart of the matter, was feeling forced to provide care that was inadequate and even unsafe.   Most of our participants reported anguish, a feeling of being professionally compromised.  Over and over again we heard, “This is not why I went into nursing.”  But there were two other common sources of moral suffering.  (2) Often nurses felt forced to work against one another rather than together.  Various budgeting and gooal-setting strategies can force units to compete rather than to cooperate.  As individuals, too, nurses watched one another stagger under their workloads and found themselves resenting anyone who so much as took a coffee break, let alone lunch – or a vacation.   Nurse managers felt this particularly acutely, as they watched for ways to motivate subordinates into still more overtime.  (3) Too often nurses felt caught within forces they could not endorse and could not change.  A simple example is hospital advertising promising what nurses cannot in fact provide.  Another is discharging patients before they are ready.  The question, then, is what could an ethics consultation do to help with such issues?  As consultations are commonly constituted, almost nothing.  The situations I’ve just described are not classic dilemmas; yet for those of us  convinced, like Sherwin and Baylis, that serving in the arena of public policy counts as ethics consultation, then this intermediate realm of hospital policy also counts.  Sherwin and Baylis speak of architecture, of creating space in which people can be heard.   Let me extend the metaphor and talk about carpentry.  On issues of institutionally-caused moral distress, providing a place at the table first requires building the table; it requires building institutional structures which encourage or require conversation.  Creating a situation in which administrators really want to listen to nurses – and vice versa – is extraordinarily difficult.  I know of no one who has managed to do it.  Yet if feminist bioethicists are to be true to their calling, they must take on this goal.Taking it on would mean reinventing “ethics consultation.”  Whatever is invented might not even be called “consultation.”  No matter.  Its implications, as always with good feminist work, would be profound.  Building this kind of table would help everyone in the hospital, every employee and every patient.  Paying attention to women, creating structures that empower them, by its very nature means paying a new kind of attention to many others: to men (since there could not be one sex without the other); to others who are disempowered (because if the oppression of women matters, so does every other sort of oppression); to the assumptions of the workplace (so often inflected by gender); and to the very categories we use to talk about all this (transgender, sexual harassment, and date rape had no names thirty years ago).    This is why the FEAST listserve is so interested in whether “duh!” is a term of derogation, why Sherwin and Baylis could write an article rarely mentioning women explicitly.  The ramification of feminist concerns is a sign of its great strength and fecundity.  But let us not forget to pay explicit attention to real women in gendered lives.  Let us not forget the nurses.  

Remember the Nurses

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Remember the Nurses

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