Letter to the Editor: Towards an "Open and Frank Dialogue"
My thanks to John Hubert for his response to my paper, "2002 CNA Code of Ethics: Some Recommendations." In replying, I am assuming (from his remarks) that he has submitted it on behalf of the Canadian Nurses Association (CNA) Ethics Advisory Committee that is responsible for periodically revising the CNA Code of Ethics. Also, I am hoping that others will pick up on points that neither Hubert nor I addressed, or on those that we did address, and that an "open and frank dialogue" (Hubert 2004: 13) about the CNA Code of Ethics will follow.
In my paper (Kikuchi 2004: 38), I acknowledge that "it is not easy to (re)formulate a sound, practical and relevant code of ethics amidst a plurality of views about ethical matters." Hubert (2004: 10) responds, "it is not only the plurality of ethical viewpoints that makes this task difficult. Balancing the need for soundness with practicality and relevance is a difficult task in its own right." With that said, he then very quickly dismisses my concerns and recommendations related to the soundness of some aspects of the Code, stating that the excessive details that would be required to address them would undermine the Code's usefulness.
I am not asking for an "exhaustive… description of justice" (Hubert 2004: 12) nor of any other of the Code's concepts, but only that they be defined, and defined clearly and as comprehensively as possible. Indeed, the kind of balance Hubert seeks is necessary; but his downplaying of soundness in striking that balance is troubling, as is his apparent reluctance to admit that the Code has problems. Also troubling are the basis, approach and process used to develop the Code that Hubert identifies in his response.
Hubert (2004: 12) explains that "the wording of the Code is intended to reflect CNA's acceptance of a reasonable plurality of views about health and the role of nurses within the healthcare system," given that it "would be arbitrary and presumptuous" (Hubert 2004: 11) for CNA to take a stand on such contentious matters as the nature of health and well-being. For this same reason, the Code is said to "remain agnostic regarding a preferred model of advocacy" and, it would seem, ought not to be prescriptive: "The best codes of ethics play a regulative rather than a strictly prescriptive role in the moral life of a profession. They ought to be prescriptive only when well-justified and firm consensus can be reached" (Hubert 2004:12). Hubert (2004:10) states that "the 2002 Code is the result of a broad-based and iterative consultation process that distilled a plurality of ethical views [italics added]...into a single document."
The foregoing enunciation of the basis, approach and process used to develop the Code helps me see that I have been functioning under several illusions. I had thought that CNA takes a position on contentious matters, basing its position on the existing evidence and reasons, and that it develops its Code through the philosophical use of reason. I had not thought that CNA would develop a code of ethics by "distill[ing] a plurality of ethical views," nor that "CNA, through the work of its Ethics Committee,… preferred a diverse eclectic approach to fulfilling the Association's mandate to establish the ethical parameters of nursing practice" (Hubert 2004:10).
Given Hubert's revelation of the basis, approach and process used to develop the Code, I now have a better understanding of why it is in the shape it is in and of what it will take to improve it. At a minimum, its improvement hinges on an open and frank philosophical dialogue about various of its aspects. For example, we need dialogue about the soundness and practicality of a code that is developed by "distill[ing] a plurality of ethical views" using "a diverse eclectic approach" (Hubert 2004:10). Since logic is not of concern in eclecticism, it would be essential to discuss our preparedness to have a code that is logically inconsistent - our preparedness to hold, at one and the same time, such claims as the following: (1) "there is room within the profession for disagreement among nurses about the relative weight of different ethical values and principles" (CNA 2002: 7); and (2) safe, competent and ethical care is one of the "eight primary values that are central to ethical nursing practice" and on which the Code "is structured" (CNA 2002: 6). If, as nurses espouse, the aim in nursing is to provide safe, competent and ethical care, then safe, competent and ethical care would have to be the chief value of the Code; and, as such, its weight relative to other values would be unarguable.
Another example of an aspect of the Code that awaits open and frank philosophical dialogue arises from Hubert's (2004: 12) strong doubt about the need for unity of nursing thought and purpose and his consequent statement that "individual nurses should be encouraged by [the Code's noncommittal to a particular view of health and well-being] to consider and expand their own views about health and wellbeing." We need to draw the implications of a code of ethics that informs nurses to practise according to their own particular views of health and wellbeing and also within which some may be contrary to others.We need to ask about the consequences of each nurse using her or his preferred definition of well-being in interpreting responsibility statements such as the following: "Nurses should…advocate for the individual if that person's well-being is compromised by family, community or other health professionals"(CNA 2002: 12).
A third and final example of a matter for open and frank philosophical dialogue arises from Hubert's (2004: 12) statement: "The best codes of ethics play a regulative rather than a strictly prescriptive role in the moral life of a profession. They ought to be prescriptive only when well-justified and firm consensus can be reached." Since the Code is replete with prescriptions that do not meet the identified criteria of justification and consensus, what are we to make of it?
In closing, I would like to emphasize that, contrary to what Hubert implies, I am not advocating that the Code's definitions and conceptions meet the criteria of certainty and noncontention but, rather, that through reasoned discussion we seek to base the Code on probable truths: truths that are "(1) testable by reference to evidence, (2) subject to rational criticism and either (3) corrigible and rectifiable or (4) falsifiable" (Adler 1965: 28). Two main presuppositions underlie my recommendations: (1) there are moral probable truths that can be attained, and (2) moral matters do not entirely lie within the realm of taste or preference. Had I been explicit about the above matters, perhaps some of Hubert's remarks might have been different.
About the Author(s)
June F. Kikuchi, RN (Retired), PhD
Professor Emeritus, Faculty of Nursing
University of Alberta, Edmonton
Adler, M.J. 1965. The Conditions of Philosophy. New York: Atheneum.
Canadian Nurses Association. 2002. Code of Ethics for Registered Nurses. Ottawa: Author.
Hubert, J. 2004. "Continuing the Dialogue: A Response to Kikuchi's Critique of the 2002 CNA Code of Ethics" [Letter to the Editor]. Canadian Journal of Nursing Leadership 17(4): 10-13.
Kikuchi, J.F. 2004. "2002 CNA Code of Ethics: Some Recommendations." Canadian Journal of Nursing Leadership 17(3): 28-38.
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