Ethical blindness

Nurses Conference 2013

Have you read your code of ethics? Probably not, says psychotherapist Philip Wright, codes usually aren’t read until something goes wrong.

An anorexic patient is refusing to eat. She has made it clear to hospital staff she does not want them to intervene. She wants to die.

Do you respect the patient’s wishes? Do you check your code of ethics? Philip Wright, a psychotherapist in private practice and a volunteer counsellor at the St James Ethics Centre* spoke to members at the 2013 NSWNMA Professional Day about moral decision-making. Why do we act one way in one case and not in another?

Phillip says the elevation of science and evidence-based practice in health decision-making can be a source of what he calls “ethical blindness”

“Ethical blindness is where you just do not see things or you refuse to recognise things. It is extremely dangerous.

“We can’t do anything these days if there isn’t evidence for it. A few years ago the Salvation Army commissioned a report on the economic impact of child abuse. Perhaps we could say ‘Child abuse is wrong. Full stop.’ But no, we need now to have an economic rationale as to why governments should act on child abuse.

“The kind of values most of us would agree with ­– fairness, working together and flexibility ­– are fairly standard principles designed to enable us to make decisions,” Philip said. “The question I have is how many times can we actually use these for our decision making. Most of the time the language that’s around values and principles is not used. We use management speak, we use scientific language, rarely do we use values and principles.

“If you create something where everything is dictated for us we lose our capacity to make responsible decisions, we become dependent on rules and regulations and codes and we lose our ability to make good decisions.

“Rules and regulations are not going to be the answer. We have to figure out what is the right thing to do, to think about and work through an issue and then do something about it.”

Phillip outlined to the audience two scenarios that show how people deal with moral dilemmas, where consequences will be similar through a person taking a particular action.

In the first case you see that the driver of a train has collapsed and died. On that track there are five people and on a secondary track there is one. By switching a lever you can cause one death but save five lives. Eighty per cent of people asked said it was morally permissible to pull the lever killing one to save five.

In the second scenario you are standing on a bridge and you see below a driverless train heading for five people on the track. The only way to stop them being killed is to throw over the bridge, and onto the track, the very large stranger standing next to you. Eighty per cent said it was not morally permissible, despite having the same outcome.

According to prominent psychologist and Harvard University professor Joshua Greene: “In the first case you are running in what we call manual mode and five from one is okay in that mode,” Philip said. “In the second case our manual mode is overridden by our emotions, in particular the emotion disgust and that says ‘no’ and that’s the critical point.

“If you think about the decisions you have to make, how many times are you going to move from a manual mode that gets emotionally overridden? It happens to all of us. It’s how we handle complex moral issues and we have to be aware of that.”

Philip was once asked to assist in dealing with the complex question of an anorexic refusing treatment.

“This is a person who had said ‘I do not want you to intervene, I’m going to refuse to eat, I’m going to die.’ The complex question was what to do now?’

“It was in hospital, surrounded by the full gamut of the health system. We had in the room psychiatrists, social workers, psychologists, nurses, and her guardian and also outside her parents and the patient. As we worked through the afternoon almost everyone was saying this is informed consent, we need to respect the patient’s wishes.

“As we walked out of the room, I thought we’d made a decision, someone said ‘yep, I get all that, we’re going to intervene’. That’s a classic case where the manual mode is over ridden by emotion.”

Philip’s role was done. It was not to make a decision, but to provide a space to fully explore the situation, to help those involved to make the best decision for the patient in line with their own values and principles.