ANS Ethics Collection – Entry 3
1983 article available for free download
1986 article available for free download
September 8 – October 8
The two articles that followed Carper’s 1979 article were authored by Roland R. Yarling and Beverly McElmurry, published in 1983 and 1986 (Yarling and McElmurry 1983; Yarling and McElmurry 1986). Their perspective is firmly grounded in nursing practice; they use real-life practice situations in developing the logic underlying their conclusion that nurses are not free to exercise their own moral agency. In the 1983 article they directly addressed the context and the situational aspects involved when a DNR order is contemplated or enacted. The assignment of physicians as the only provider authorized to write a DNR order is not justified. They point to the fact that nurses spend the vast majority of the time any provider spends with patients, and knows the situation as well as it can be known. Nurses are therefore well positioned to take responsibility for acting in the best interest of the patient when any weighty decision is contemplated.
Yarling and McElmurry note that nursing has long wrestled with the vestiges of nurses as handmaidens to physicians, and the contested social positioning of women as subservient to male authority. When nursing education first introduced the idea of nursing as an autonomous profession with the core duty to serve the interests of their patients, the practice arena did not model this ideal, reinforcing the struggle to exercise moral authority in practice. At the time this article was published, this disconnect may have shifted in many contexts, but it remained like a dark cloud hovering over many real-world situations. They stated:
“The business of setting the nurse free to practice nursing, ie, free to be moral, must proceed on various fronts. It is partly a matter of nurses achieving internal or psychological freedom after generations of socialization in a subordinate role both as nurses and women; it is partIy a matter of nurses acquiring the appropriate paradigm to understand the nature of health care and their role in it, and it is partly a matter of institutional reform” (Yarling and McElmurry 1983, page 9)
This perspective established the idea that nursing ethics is a social ethic. In order for nurses to be free to act morally, we also must address the moral obligations of the institutions in which we practice.
In their 1986 article, Yarling and McElmurry moved away from the specific consideration of DNR orders. They expand the argument that nursing ethics is not only a social ethic – it is even a reform ethic. In other words, the constraint of hospitals in restricting nurses moral authority is not a restriction on the will to act morally; it is a restriction on actions arising from our moral sensibility. They again turned to nursing practice, and the frequent circumstances in which nurses are at risk of losing their jobs if they do not conform to hospital, and often physician authority. They cite numerous examples in which nurses faced grave risk in attempting to act on behalf of their patients. They concluded:
“The risks involved when nurses choose to act on behalf of patients whose rights are in conflict with the interest of the hospital are grave indeed. It is an indubitable fact for those who know the subculture of the health care professions and the power structures of hospitals that nurses who openly challenge established authority structures or powerful physicians in a hospital bureaucracy most often put their jobs, their economic welfare, and their professional careers on the line, even if they are acting on behalf of the patient and have strong justification for doing so.” (Yarling and McElmurry 1986, page 70)
Yarling and McElmurry acknowledged that there is a tendency for nurses to prefer an apolitical stance, with a priority for serving individuals in need rather than spending energies on the needs of organizations or social movements. However, nursing does have a rich tradition of social reform initiatives by nurses who recognized the collective needs of populations in order to best serve individual needs. “The one action that would most improve the quality of health care in this society is simple and direct: Set the nurses free, set the nurses free.” (Yarling and McElmurry 1986, page 73)
Stay tuned for the next entry in the ANS Ethics Collection! We will explore the 1987 article titled “Nursing Ethics in an Age of Controversy” by Anne Bishop and John Scudder. Here is the published abstract for this article:
“Nursing ethics is examined within the context of the health care controversy concerning care vs cure. Yarling and McElmurry’s contention that nursing ethics should focus on autonomy and reform is critically appraised. In opposition, the moral sense of nursing practice is affirmed as the primary focus of nursing ethics. Reform concerns enhancing excellence in nursing within an expanding legitimate authority. The “in-between” situation of nurses is regarded as an excellent position from which to foster communal decisions by teams of health care workers engaged in the moral practice of fostering the well-being of the ill.” (Bishop and Scudder 1987)
Sources
Yarling, R. R., & McElmurry, B. J. (1983). Rethinking the nurse’s role in “do not resuscitate” orders: a clinical policy proposal in nursing ethics: a clinical policy proposal in nursing ethics. ANS. Advances in Nursing Science, 5(4), 1–12. https://doi.org/10.1097/00012272-198307000-00004
Yarling, R. R., & McElmurry, B. J. (1986). The moral foundation of nursing. ANS. Advances in Nursing Science, 8(2), 63–73. https://doi.org/10.1097/00012272-198601000-00010
Bishop, A., & Scudder, J. (1987). Nursing ethics in an age of controversy. ANS. Advances in Nursing Science, 9, 34–43. https://doi.org/10.1097/00012272-198704000-00011