DIFFICULT MORAL QUESTIONS

Question 77: Should a nurse stay on in a hospital to oppose injustices against patients?

When I finished nursing training last year, I came to work here in this public hospital. Many of our patients are poor, uneducated people, cared for almost entirely by residents and interns, though nominally assigned staff physicians. The way they are treated is appalling in many respects, but what bothers me most is that consent is nothing but a formality. They routinely sign forms at admission, so we have consent to anything and everything that might be done to them while here. The doctors, with few exceptions, hardly talk to patients except for diagnostic purposes, brush their questions aside, and put them through examinations, treatments, and even major surgery without explaining what is going on or giving either them or their families any real chance to refuse. I try to answer their questions when I can, and in a few cases have gone so far as to suggest to a patient that he or she need not go along with what a doctor was planning. For doing this, I have been scolded repeatedly for wasting time, and doctors several times have told me to mind my own business. Yesterday the head nurse called me in and reprimanded me. I pointed out that many other nurses share my dissatisfactions and constantly gripe about how the doctors deal with patients and ignore their rights. She admitted that not everything is done here “in the ideal way,” but excused the doctors because they are tired and overworked, and said informed consent is meaningless for most of the patients we deal with.

I do not know what I should do, but I do know I cannot just stay here, do as I am told, and go along with the way things are done. I could quit and go to work elsewhere, and that is what I am inclined to do. I am the kind of person who likes to get along with everyone, and I always was an obedient daughter and a “good girl” in school. Still, when I put myself in the place of my patients, I feel as though I should do something about this situation. But the thought of fighting for better treatment for my patients really frightens me. Besides, I do not know what I could do that would make any real difference.

Analysis:

Though patients are being dealt with unjustly in the hospital where the questioner works, she can do her own work without wronging her patients, and so need not quit and go elsewhere. At the same time, though she could remain and work to mitigate the evil, she apparently has no strict duty to do that. Therefore, the question calls for discernment between two morally acceptable options—staying and quitting. Since the questioner seems well aware of factors pointing to a decision to quit, her discernment can be assisted by calling attention to factors pointing to a decision to stay and sketching out steps she might begin to take to try to obtain justice for her patients.

The reply could be along the following lines:

Obviously, patients’ limited ability to understand options and their limited freedom due to psychological factors can make them more or less incapable of consenting to various forms of care and treatment. However, failing to obtain truly informed and specific consent, insofar as patients are capable of it, gravely violates their fundamental human and legal rights: both their right to decide what potentially burdensome things will be done to them and their right to shape their health care so that it will be harmonious with other aspects of their lives. Moreover, patients whose informed consent is not obtained are ill served, for they are not helped to understand their problems and assume responsibility for them as they must if they are to care for themselves, with their families’ or others’ help, after being discharged from the hospital. It is gravely dishonest to reduce obtaining patients’ consent to a mere formality, since the purpose of getting their signature is to provide evidence, if it becomes needed, that genuine consent was given. Finally, using the patients’ poverty and lack of education to rationalize this abuse manifests willingness to discriminate against them in a way that gravely violates their essential human dignity. Therefore, it is a great evil to make these patients’ consent a mere formality.

Even so, you need not personally share in the guilt for the mistreatment of your patients, provided you do all you can under the circumstances to care for them properly and refuse to lie or do anything else wrong in itself. But while you should not feel obliged to quit, nothing in your letter indicates that you have any obligation to remain, and so you could in good conscience go to work elsewhere. Your personality and limited professional experience might make it pointless for you to try to do more about the situation than you already have; perhaps you would do well to accept your inability to remedy these evils, at least here and now, and move on. But perhaps you are being called to rise above yourself and do more to serve your patients. Consequently, your question can be answered only by discernment.

You are understandably anxious and hesitant, but those feelings may not reflect the requirements of the real situation and your better self. You prefer to be docile, but you are spirited enough to feel you should do something. Remember that even Jesus was anxious in the Garden of Gethsemane, and try to put your anxiety aside as you seek to discover God’s will in the matter.

In discerning, gather the facts about your options, and consider them calmly and carefully. Consider all your gifts and limitations, the possibilities of serving in a different situation and perhaps developing your ability to deal with problems similar to those that have aroused your concern, the possibility that you will be able to do something toward meeting your present patients’ needs, and the likelihood that someone else will do what you will not if you go elsewhere. Then, praying for the light to discover God’s plan for you and calmly reflecting, compare your feelings about your employment options with the feelings integrated with your Christian faith and professional commitment, and choose the option—staying or moving on—that seems preferable.

To help with your discernment, you would do well to seek the advice of an older colleague of good character and long experience—someone you trust and admire, perhaps a former teacher or someone you served under during your training. Such a mentor could not only provide information you lack but help you put your present experience and dissatisfactions in perspective. Should you decide to remain in your present job, such a person also would be a great help in planning how to carry on the struggle.

While not presuming to discern for you, I note that you seem to be focusing on reasons to leave, and I urge you also to consider everything pointing to a decision to stay. On the one hand, reform in the hospital is badly needed, and your account offers no ground for optimism that others will strive to meet that need. On the other hand, you have certain gifts necessary to work to rectify the abuse. You have clear insight into the injustice and hate it, while others resignedly tolerate or even endorse and defend it. You do not think of yourself as aggressive, but your persistent efforts to vindicate patients’ rights manifest courage, and this character trait will grow as you exercise it. Since how patients are treated is your business and answering their legitimate questions is an appropriate use of your time, the scoldings and reprimand you have received plainly were unfair, and their very unfairness would count in your favor if the conflict generated by your behavior became public. Finally, since you have other appealing employment opportunities, you can risk your job without fearing that losing it will prevent you from meeting your responsibilities to care for yourself and your dependents, if any.

How might you proceed if you do opt to stay and struggle for better treatment for your patients? You say you do not know what you could do that would make any real difference, and if you take too broad and long a view, you are indeed likely to find the prospect daunting. I suggest that, at least at the outset, you focus instead on simple things you can do at once, and start doing them day by day.

Begin by thinking about your relationships with your fellow workers and determining your stance toward them.

Some have opposed your efforts to serve patients as they should be served. Their attitudes and actions plainly are wrongful, but only God knows how great the physicians’ and head nurse’s responsibility is. It probably is true that the physicians are tired and overworked. Residents and interns in many hospitals work absurdly long hours, and staff physicians often are responsible for more patients than they can serve adequately. In many cases, nurses should explain treatment options to patients and answer their questions, but the head nurse’s reprimand perhaps is a sign that staffing is inadequate to carry out properly both this duty and others she regards as more essential. Very likely, your hospital’s budget restrictions and screening procedures effectively ration health care for poor and uneducated people, so that they cannot obtain the minimum level of service to which they are entitled in strict justice. That structural injustice almost compels personnel working within the system to compromise professional standards and violate patients’ rights. The only adequate remedy for the bad practices you describe, therefore, would involve not merely changes in individual physicians’ and nurses’ attitudes and behavior but a more adequate budget and better administration as well.

Therefore, you should regard these fellow workers neither with hatred and anger nor with fear and submissiveness. Deal with them as you do with patients who present problems. Be unfailingly polite and friendly; focus on the business at hand and the purposes you wish to achieve; ignore anything unpleasant they say or do unless it will have practical consequences; and find appropriate ways to deal with anything significant they say and do. For example, if you think the head nurse’s reprimand was mere talk, you need not make an issue of it; but if you think it was a threat to discharge you if you do not stop doing what you believe your professional responsibility toward your patients requires, perhaps you should write the hospital administrator a letter (with a copy to the head nurse) laying out the problem and asking for guidance.

You indicate that a few exceptional doctors deal with patients more appropriately than the rest, and that many other nurses share your dissatisfactions. Regard all these people as potential allies. Discuss your concerns with them, ask them to share their views with you, and listen carefully to what they have to say; after all, you have been at the hospital only a year or so, and probably have much to learn. As you get to know them and their reasonable dissatisfactions with the situation, do not let your conversations become bogged down in sterile griping. Instead, ask what they think might be done to improve matters. If some seem able to speak out against abuses, urge them to do so, since even a small chorus of criticism is much harder to disregard or silence than an isolated voice. If someone seems more suited than you to exercise leadership, urge that person to take on that role and promise to help him or her enlist others.

Probably many of your fellow workers who conform to the common pattern are not antagonistic toward you and others who deviate from it. Gently sound out these people about their attitudes. In some cases you will find that they share your views and deplore the injustice toward patients, but have resigned themselves to it, hopelessly feeling that nothing can be done to improve matters. Try to arouse their dormant professional idealism and encourage them, if not to act and speak out, at least to support you and others who do. If they respond at all, show your appreciation. The moral support of this seemingly inert mass of people is likely to be critical if your work for reform eventually provokes serious retaliation from the hospital administration.

Support also might be available from other quarters. Some members of the governing board might be sympathetic and willing at least to investigate the situation. If you belong to a nurses’ union, the union might help you defend the profession’s standards and safeguard your position. If the hospital has a quality-control committee or an ethics committee, providing it with factual information about especially egregious cases could provoke action that would lead to more general reforms. Perhaps the staff and its auxiliaries include social workers, psychological counselors, patient advocates, chaplains, or others concerned with patients as persons and with their families. They are likely to include some natural allies who could bring pressure to bear on the administration and/or the clinical staff.

You also might try to form an interreligious prayer group with the faithful Catholics and other devout Christians among your fellow workers. With such a group, you could begin to try to develop a dialogue about conditions in the hospital, focusing first on the facts, then reflecting on them in the light of faith and the norm of love of neighbor, and prayerfully considering even the smallest concrete steps that might be taken to improve matters.

Moreover, it is likely that nearly everyone working in the hospital shares a common interest in obtaining more funding. Whenever you have the chance, you could make an effort to further this cause—serve on committees, testify at hearings, write letters to the editor, and so on. In this way, your fellow workers would come to think of you as someone dedicated to the common interest rather than as a mere troublemaker.

Under suitable conditions—and perhaps as a last resort—you might even look outside the hospital for help. If there are any large benefactors, you might arouse their interest in the matters that concern you. Careful documentation of abuses could lead some relevant official body to investigate the hospital’s policies and practices. The editor of the local newspaper might be willing to speak with you confidentially; if so, you could provide him or her with factual information that could lead to a journalistic exposé. You might be able to enlist a public interest group or leader of a minority to assume an advocacy role for your patients. Perhaps a public official or one of the politicians who deals with the hospital’s budget would be sympathetic to your concerns.

If you stay at the hospital and struggle to improve conditions, you surely will suffer. To endure that suffering without resentment toward those responsible, you will have to draw close to Jesus and learn from him how to love and forgive them. Strengthened by prayer and the Eucharist, you will be able to bear your cross. Choose a suitable saint, someone like Peter Claver, as the patron of your struggle; learn about your patron, become his or her friend, ask for this friend’s intercession, and confidently expect the heavenly help you will need.

Above all, be firm in hope. Measure your success, not against the ideal the hospital should meet, but against the worse treatment this or that particular patient would endure if you were not carrying on your struggle. Each time you confer some small benefit on one patient or prevent some small harm to another you will achieve something of great worth. Every one of your poor and uneducated patients has been called to be a member of Jesus’ body, and you do for Jesus what you do for each of them (see Mt 25.40).