Commentary on Ersoy et al.

- Masahiro Morioka
Integrated Arts & Sciences, Osaka Prefectural University,
Gakuencho, Sakai, Osaka, Japan 593

Eubios Journal of Asian and International Bioethics 7 (1997), 170.

Ersoy et al. show us some significant inclinations contemporary Turkish nurses have in their clinical settings. Recently, in Japan, nurses are becoming more and more sensitive to ethical issues arising from contemporary medical developments. They are trying to speak out ethical dilemmas they are faced with, and resolve them with the help of a variety of people outside the nursing world. But, of course, this is not an easy way to go. I think it would be fruitful that nurses from Asian countries get together and discuss ethical issues, and compare nurse-physician-patient relationships in their countries with various cultural and religious backgrounds.

Ersoy et al. discuss patient advocacy and say that "in the case of a patient lacking the ability to behave independently," patient advocacy "encompasses communicating, making appropriate decisions, and performing a wide range of duties one of which is having to derive a decision on behalf of the patient without necessarily getting the patient's wishes or participation. In these circumstances, it is important that nurses consider the patient's real needs and wishes and that the patients not be abused." This is the point where many difficult ethical issues arise from in nursing. Nurses usually work bedside and spend more time with patients than physicians, hence nurses sometimes get to know small but important ethical issues which physicians usually do not notice. In addition, nurses stand between physicians and patients; this naturally leads nurses to take an advocacy role on behalf of the patients. But is it really possible for a nurse to fully advocate patient's interest? Is it, on earth, really possible for someone to know a patient's "real needs and wishes" even if the patient have clear consciousness?

I am not trying to criticize Ersoy et al.. I agree with them on the point cited above. But there exists a difficult philosophical problem. We all know it is not so easy for patients to say their real needs and wishes to their physicians because there is usually unequal power relationship between the two parties. Similar things may happen in the case of the patient-nurse relationship. Nurses are really compassionate. They care patients in a way most people never be able to perform. Patients have full of gratitude toward nurses. However, the more patients feel gratitude toward nurses, the less patients be able to speak out their "real needs and wishes" in the case that nurses' approaches are, in fact, contrary to the patients' inner will. This is, in a sense, another form of paternalism.

Generally speaking, health care professionals have to continuously fight against their inner inclination to be excessively paternalistic toward patients/clients. Of course Ersoy et al. know this very well. They note that nurses have to "consider the patient's real needs and wishes and that the patients not be abused." But, at the same time, nurses passion for knowing patient's real needs and wishes may sometimes suppress the patient's courage to tell the real wishes when the patient love the nurse's personality and her passion. As Ersoy et al. point out, nurses become paternalistic when patients are children. This reflects the parent-child relationship in a family everywhere in the world. We have to distinguish acceptable paternalism from unacceptable one, but making this distinction is really difficult.

My point is that physicians are paternalistic in many cases, but at the same time, nurses can sometimes be paternalistic toward patients under the name of love and passion. Hence, when a nurse advocate patient's needs and wishes it would be better for her to bear in mind the power relationship between a nurse and her patient that may not be easily found through her eyes in clinical settings.

Reading their paper, I come up with a simple question: what kind of attitudes do nurses take toward the elderly and/or physically/mentally disabled patients? Do they treat them in a way which they do toward children? Are there any special difficulties they are faced with in such cases especially when nurses try to advocate these patients?

In Japan, care of the elderly and the disabled is becoming a big ethical problems because in 2025 one fourth of the Japanese is supposed to be over 65, and the number of younger people will be rapidly decreasing. Hence we will have to advocate many more people in hospitals and nursing homes. This may create grave ethical issues in the near future.

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