Book Review: Ethical Dilemmm &Nursing P r a i a

Patricia Murphy

Anne J. Davis et al., Ethical Dilemmas 6 Nursing Practice (Stamford: Appleton & Lange, 4th ed., 1997): 275 pp., ISBN 0-8385-2283-1 (paper), $34.95. To order call 1-800- 423-1359.

hearty perennial is back in a new and improved edition. Now in its fourth edition, Ethical Dilem- A mas 6 Nursing Practice remains a solidly valu-

able textbook and resource book, especially suited for gradu- ate education. Its particular strength is its solid theoretical and historical background for understanding the ethical dilemmas faced by nurses in these most turbulent times. This book is one that should be in every nursing library and in every advanced practice nurse’s office.

The first chapter, “Health Care Ethics and Ethical Di- lemmas,” illustrates the continuing strength of this book. In just sixteen pages, the authors clearly provide a concep- tual and historical framework for modern health care eth- ics, sweeping from Plat0 to the hospital ethicist and from the Greek roots of ethos to the role of code-making in the culture of contemporary health professions.

The next chapter is a new contribution. Marsha Fowler, whose expertise on codes of ethics is well established, traces the changing nursing ethos through more than 100 years of American nursing education and publication. This chapter provides enough personal vignettes and illustration to give a lively sense of just how far nursing has come since Florence Nightingale’s Crimean War-influenced emphasis on sol- dierly obedience as the foreground virtue for the good nurse.

A brief chapter on moral development is followed by an admirably clear and editorially disciplined chapter on ethical theories. This book is not focused on introducing

Journal of Law, Medicine &Etbis, 25 (1997): 65-66, 0 1997 by the American Society of Law, Medicine & Ethics.

or illustrating or helping readers to master alternative ap- proaches to the resolution of ethical dilemmas. Hence, these chapters, although essential, are appropriately brief. Within the overall scope and purpose of the book, their brevity is a strength.

The next chapter is one of my favorites and, indeed, may be seen as the functional centerpiece of the entire vol- ume. Entitled “Professional Ethics and Institutional Con- straints in Nursing Practice,” this chapter explores how features of the organizational and social landscape influ- ence both the shape of ethical dilemmas and the responses to them of conscientious nurses. Here, we encounter the “nurse in the middle” phenomenon, which seems to char- acterize nursing ethics. The role of gender differences and historical power differentials between physicians and nurses is well explored. I am puzzled why the authors do not point out that, at least in the best of baccalaureate nursing pro- grams, ethics courses are often paired with teaching about organizational systems theory and an attempt to develop the skills of effecting organizational change.

A series of chapters treat specific topical areas in health care ethics, such as informed consent, abortion, mental retardation, and behavior control. These chapters have been updated, though somewhat unevenly in my judgment. For example, the well written and up-to-date chapter “Dying and Death” incorporates recent developments regarding professionally assisted suicide. On the other hand, the chap- ter on health care policy, although sprinkled with newer references, is only modestly enhanced by the ideas expressed in those works.

Indeed, a disappointment with this new addition is that the authors barely acknowledge, let alone describe or explore, the turning fortunes of nursing in the political arena. The 1990s have been distinguished by an unprec- edented level of public policy activity and effectiveness on

.

65

Volume 2511, Spring 1997

the part of organized nursing. Although it may be some- what too soon to evaluate this phenomenon confidently, it is surely time to take note of it.

This book is theoretically dense. That is, it is not liber- ally seeded with illustrative cases or accounts of nurses struggling to discern “the right thing to do.” The cases that follow some chapters are realistic and well thought out. Any nurse in practice will recognize these patients and situ- ations as apt examples of their everyday experiences. These cases are presented not so much to review or illustrate con- cepts introduced in the text as to afford opportunity to use

the concepts in ways not yet explored. That is, rather than testing the reader’s comprehension of what has gone be- fore, the cases tend to invite further thinking.

The text, if conjoined with lively teaching by a nurse with considerable current clinical involvement, could be an apt choice for generic nursing education. However, I can more confidently recommend it for experienced nurses whose educational need is not to learn how to address ethi- cal challenges inherent in nursing practice, but to gain his- torical and theoretical perspective on nursing’s effort to grapple with them.

66