Journal ofmedical ethics, 1990, 16, 179-184

Specialists without spirit: crisis in the nursingprofessionSoma Hewa and RobertW Hetherington University ofBritish Columbia and University ofAlberta, Canada

Authors' abstractThis paper examines the crisis in the nursing profession inWestern industrial societies in the light ofMax Weber'stheory ofrationalisation. The domination ofinstrumentalrational action in modern industrial societies is evident inthe field ofmodern medicine. The burgeoning mechanisticapproach to the human body and health makes modernhealth care services increasingly devoid ofhuman values.Although the nursing profession has been influenced byvarious changes that took place in health care during thelastfew decades (for example greater reliance ontechnology), the underlying values ofthe nursingprofessionstill emphasise a broad definition ofthe well-being ofpatients. Hence, in recentyears the irrational consequencesofgrowing technological medicine in North America hasresulted in a serious crisis in the nursing profession. Toresolve this crisis the authors propose a reorganisation ofmodern health care services on the basis ofa newparadigmwhich is compatible with both the health care needs of thepeople and the main emphasis in education and trainingofthe nursing profession.

Classical sociological theorists provide an excellentframework for interpretation of modern social issues.One such theorist, a founding father of modemsociology, is Max Weber. A major emphasis inWeberian theory is the examination of thedevelopment of modern Western social and economicinstitutions arising from the influence of theReformation. Weber recognised the Reformation as aturning point for modern Western civilisation,breaking away from the dominant influence andteaching of the Catholic Church. The uniquecharacteristic of modern Western civilisation,according to Weber, is the process of rationalisationwhich began with the sixteenth and seventeenthcentury Reformation. Rationalisation, for Weber,involved turning away from traditional ways ofthinking, toward the logical application of rationalthought. This process freed the individual to definehis/her own destiny, and to choose rationally amongst

Key wordsNursing ethics; rationalisation; mechanistic model; nursingvalues; health care paradigms; technology.

various alternative courses of action to attain desiredends. It also resulted in demystification ofmany thingsin society, and developed the belief that problemscould be solved by logical intervention rather thanappeal to higher powers.Weber referred to rationalisation as 'instrumental

rational action' which he defined as

'...based on purely rational choice among possiblemeans to obtain certain defined goals. Hence, onechooses the means methodically and rationally in viewof a specific goal and in this context, values maybecome obstacles to achievement of the goal' (1).

The last part of Weber's definition of instrumentalrational action suggests the emergence of a paradox:that is, the very achievement of goals through rationalaction may result in erosion of values. In recent years,a number of scholars have tried to draw attention tothis paradox in Weber's theory (2,3,4). The purpose ofthis paper is to pursue the paradox of rationalisation interms ofsome 'irrational' outcomes in modern Westerncapitalist social structure, particularly with referenceto the dominant system of health care. Weber himselfforesaw the paradox, the 'irrationality', in his famousmetaphor of the 'iron cage' where he referred to thedestruction of fundamental social values in the face ofgrowing rationalisation.

This destruction of social values has resulted in aserious crisis in health care. For instance, in thenursing profession there are indications of a conflictbetween the process ofrationalisation and fundamentalvalues traditionally associated with the profession. It isargued here that growing pressures to implement amechanistic medical model in nursing tend toundermine such basic values of the nursing professionand lead to job dissatisfaction, stress, frustration andconfrontation between nurses, physicians and healthcare administrators. To resolve this crisis in nursing,the professional values of nursing themselves must bere-established on the basis of its original paradigm.The cornerstone of the original nursing paradigm asdeveloped by Nightingale and others, was to providehumanitarian caring for the sick and the disabled (5).This approach did not make a distinction betweenphysical, psychological, social and spiritual aspects of

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180 Specialists without spirit: crisis in the nursing profession

human existence, but rather treated them together in aholistic fashion.

Disenchantment of the worldAs suggested earlier, the manner in whichinstrumental rational action dominates modernWestern societies was foreseen by Max Weber.Instrumental rational action, Weber contended (1) isbased on a purely rational choice amongst possiblemeans to attain certain defined goals. Hence, onechooses the means methodically and rationally in viewof a specific goal. He argued that one outcome of thisrationalisation is a 'disenchantment of the world'which has taken place in the West more than anywhereelse. This means that virtually all spheres of Westernculture and social organisation have undergone theprocess of rationalisation, so that in principle, there areno mysterious unknowable powers and humans canmaster everything through technical and practicalmeans. In The Protestant Ethic and the Spirit ofCapitalism (6), Weber defined the process ofrationalisation as ideational intentionality - that is,humans are not at the mercy of historical forces thatthey do not control. In action which is purposive-rational, every individual has prior knowledge of his/her action, and therefore, outcomes of such actions arepredictable. That is, individuals are always capable,according to Weber, of eradicating irrationalconsequences of their own actions by choosingalternative courses of action which will counteractuntoward outcomes and which are compatible withdesirable political and social conditions.Weber believed that people create their own history,

and that they have sufficient freedom to do so. In thisregard, Weber believed that the Marxist interpretationof history has made an important contribution (6) inthat Marx emphasises the autonomy of consciousindividual action in the unfolding of historicaldevelopment. On this point, Marx and Weber are inagreement. Rationality, according to Weber, is thefreedom to accomplish what is desirable for theindividual, even when such freedom may result in theundermining of values of the larger social system. Themeans and ends of such action may not always besocially acceptable, but insofar as the individual'spurpose is concerned they are rational. The rationalconsideration of the given means in relation to the self-postulated purpose, and the relation of the purposeitself to the chances and results of its attainment,constitute the responsibility of free and rationalconduct (7). The implications of rationality, as definedby Weber, include such outcomes as calculability,predictability, freedom of choice and practicality(efficiency), which are all fundamental elements ofmodern industrial capitalism. Thus, rational action isthe freedom to pursue any goal which is attainable bycalculable, predictable and practical means freelychosen. It is emphasis on these 'means' that isdescribed by Weber as being rational in modernindustrial society.

Weber realised, however, that the process ofrationalisation would have adverse effects on humanvalues in the West by eliminating the sense of dutybased on values which binds individuals together (8,9).In concluding his well-known lecture on Science as aVocation in 1918 at the University of Munich, Weberpointed out this paradoxical nature of the process ofrationalisation in modern Western societies. 'The fateof our times' Weber maintained (10), 'is characterisedby rationalisation and intellectualisation and, aboveall, by the disenchantment of the world. Precisely theultimate and most sublime values have retreated frompublic life either into the transcendental realm ofmystic life or into the brotherliness of direct andpersonal human relations'. Modern Western societies,according to Weber, are moving, towards aninescapable danger (iron cage) from which they cannever be rescued: the impossibility of preservinghuman values in the face of scientific rationalisation.Weber said:

'...for the last stage of this cultural development itmight well be truly said: specialists without spirit,sensualists without heart, this nullity imagines that ithas attained a level of civilisation never beforeachieved' (6).

This is the end of Western industrial civilisation, asWeber foresaw it.

The Cartesian paradigm in modern medicineThe penetration of instrumental rational action intomodern industrial societies has been a distinctivefeature of the West. This is specifically true in the fieldof modern medicine. It should be emphasised,however, that medicine did not develop in ahumanitarian vacuum: efforts of the medicalprofession throughout history were driven primarilyby a desire to alleviate the suffering of mankind. Theorientation of medicine throughout history has been toseek solutions to the suffering of mankind throughtechnological advances which concentrated on viewingthe body as a mechanical system in need of repair (forexample, the work of Robert Koch, Louis Pasteur).There were competing paradigms to the dominantparadigm, such as that advocated by such importantfigures as Virchow and Engels, but these paradigmswere not successful in gaining dominance in the field ofmedicine.

According to Sheila Hillier (3) the development of amechanistic approach to the human body in modernmedicine originated with the discovery of thecirculation of the blood by William Harvey (11) in theearly seventeenth century. Harvey's discovery waslater supplemented by the publication ofthe Treatise onMan (12) by Rene Descartes, in which the human bodywas clearly separated from the mind. Cartesiandualism recognised the human body as analogous tothe machine which is composed of separate butinterdependent parts (13). This mechanistic view of

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Soma Hewa and Robert W Hetherington 181

the human body grew apace with subsequentdiscoveries in medicine which reinforced the view thatillnesses are results of the failure of mechanicalfunctions of various parts of the human body. AsHillier argues, rationalisation in the West furthered thedevelopment of a mechanistic paradigm in modernmedicine which contradicts the traditional view of thenature of humans.Within this paradigm it is believed that technical

progress in medicine will somehow resolve all healthproblems. This belief, as Ray Jackson argues (14), isemphasised particularly by medical specialists whoseskills are based on the use of modern medicaltechnologies, and who attempt to master human lifethrough technology. Paul Starr (15) goes as far as torecognise a medical industrial complex (composed ofdoctors, hospital managers, health insurancecompanies and medical technology manufacturers)emerging as a result of the dominance of themechanistic paradigm in health care.The paradoxical nature of technological growth in

modern medicine has resulted in the one-dimensionalcharacter of the contemporary health care system.Health care services are increasingly devoid of humanrelations (16), and individual patients are treatedwithout regard for psychological, social and culturaldifferences. It is a common belief among physiciansthat medicine is a science and humans are complicatedmachines that break down. Everything that happens toa patient can be explained in scientific terms.Psychology, spirituality and emotions are not regardedas important aspects of medicine, nor are they part ofmedical jargon. Therefore, aspects of the patient'sproblems which are accessible to scientific interventionand analysis will take priority, while those aspectswhich are less well comprehended (emotions,spirituality, social well-being) are likely to be ignored.This results in doing what is technologically possible,rather than in doing what may be in the best interestsof the patient, all things considered.The persistent emphasis on technical aspects of

health care services has led to tensions between thenursing profession and physicians, patients andphysicians, and the nursing profession and health caremanagement. These tensions are clear examples of theirrational outcomes of growing rationalisation(instrumental rational action).

In the following section, we discuss the majorpresuppositions of the nursing profession and howthey conflict with the assumptions of the mechanisticparadigm in medicine.

Nursing: trapped in the iron cageIt can be argued that both medicine and nursing hadreligious, spiritual or metaphysical origins. Inmedicine, such origins continued to have dominantinfluence over the thinking of practitioners roughlyuntil the seventeenth century. However, following theReformation, medical scientists such as Harvey beganto question the religious and metaphysical bases of the

human body and explanations of health. Directobservation and experimentation became an acceptedprocedure in medical science and teaching. Suchscientific approaches slowly discredited the traditionalintepretations in medicine, and tended to change thegeneral orientation of medicine to a more mechanisticone. Subsequent discoveries and their successsupported the idea that the body could be understoodand treated as a series ofinterrelated mechanical parts.Unlike medical science which grew towards a more

mechanistic view of the human body and health,nursing from its inception maintained a totallydifferent perspective on health care. One of the mostimportant reasons for this difference is that nursingemerged as a secular occupation from a religiousbackground. Even though both nurses and physiciansworked in the same environment, this differenceremained. From the beginning, nursing wasinfluenced by Judaeo-Christian values which shapedthe occupational goals of the profession. As themajority of nurses working in hospitals during theearly part of the nineteenth century were RomanCatholic nuns, their services were generally regardedas a humanitarian gesture towards the poor, sick anddisabled segments of society on the part ofthe Church.Also, such tasks provided spiritual satisfaction fornurses who believed that helping the diseased and lessfortunate was the most appropriate means of attainingsalvation (17).The reorganisation of modern nursing in the

nineteenth century was initiated by FlorenceNightingale who believed that nurses were capable ofproviding care for the sick and the poor in a moreorganised and professional manner than was thecustom (18). However, the prime motivation that ledNightingale to reorganise nursing stemmed from herstrong commitment to the Judaeo-Christian beliefsystem. She felt she had been called by God to theservice of the poor and the sick and thus despite thestrong opposition of her middle-class family,Nightingale pursued her vision until she and her fellowgentlewomen were given formal status in the healthcare system by the authorities. Her struggle to gainrecognition for nursing was by no means an effort tocreate an independent profession of nursing in thesystem of health care delivery. Therefore, as LindaAiken (19) argues, nursing from the beginningattempted to accomplish two fundamental goals: first,for nursing to become an ancillary medical occupation,dedicated to maintaining the comfort and well-being ofthe sick and the disabled; second, for nurses to becomeobedient and disciplined assistants to physicians, andto be involved in hospital ward organisation andmanagement.

In contrast to the medical profession which grewmore attached to the mechanistic paradigm because ofscientific and technological discoveries in medicine,nursing somehow managed to continue to emphasiseits fundamental ideals of humanitarian concern forpatients (20). Hence, despite the mechanistic view

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182 Specialists without spirit: crisis in the nursing profession

dominating medicine, nursing remained within thetraditional (original) paradigm. Although 'nursing' as asecular occupation became involved with variouschanges that took place in health care in modernindustrial societies (for example, greater reliance ontechnological devices), the underlying values of thenursing profession still emphasise a broad definition ofthe well-being of patients (21). Hence in recent yearsthe growing emphasis on technological medicine inNorth America has resulted in a serious crisis in thenursing profession (see for example 22,23,24).While the medical profession and health care

administrators are attempting to expand the utilisationof technological devices in medicine, members of thenursing profession are striving to cope with theirhumanitarian consequences. Therefore, nurses aretrapped between two competing paradigms. They areobedient assistants to physicians and are underpressure to follow the mechanistic approach to healthand illness, since they must provide care on order fromphysicians. Further, the care that they provide now forthe most part involves mechanised care. In otherwords, much of their work involves specialisedtechnical tasks which require monitoring theperformance ofsome mechanical support or diagnosticsystem. Thus, there is little opportunity for initiativeon the part of nurses. They are not able to respond tothe suffering or the needs of the patients; rather theyare forced to respond to the needs ofthe physicians andthe mechanical systems in which they have becomeenmeshed. This leads directly to a fundamentalcontradiction, a 'feeling of disappointment with careerand professional development as well as adisappointment over the ability to fulfill professionalnorms' (25).Although academic and professional training in

nursing still emphasises social and humane aspects oflife (26), once nurses become part of the health caresystem their task suddenly becomes subordinated tothe mechanistic paradigm ofmedicine. They have littlevoice in determining the nature of their services, andthey have little participation in the process of decision-making. Physicians decide who should receive whatservices even though the nurses often have to face theday-to-day realities of patient suffering. Nurses workin a two-dimensional world. In one dimension the viewheld by physicians and hospital management is moreconcerned with the application of mechanisticsolutions to medical problems (curing the illness). Inthe other dimension, nurses are concerned not only withapplying mechanical solutions but also with caring forthe total well-being of the patient (includingpsychological and physical comfort) and thusemphasising traditional, fundamental values of thenursing profession.As in any other area of life in modern industrial

society, health care has been experiencing a wide rangeof technological revolutions. The most salient aspect ofmodern medical organisation is the extent to whichphysicians have divided themselves into specialties

which are the result of growing technological andscientific innovations (27). These specialties are largelyindependent ofone another and each specialty has littleknowledge of other areas that are not included in thatspecialty. This fragmentation encourages specialists tomake decisions on various health care services that donot take into account the 'whole patient', includingher/his social, cultural, emotional and psychologicalcharacteristics. The process of specialisation and thedevelopment of technological solutions to problems is,on the surface, a rational approach. However, whenrationalisation becomes dogma, as is the tendency inmodem society, then the approach may be appliedindiscriminately and at the expense of otherconsiderations which consequently go withoutattention. Then rationalisation becomes 'irrational'(28).By contrast, nursing programmes are still based on

the fundamental idea that the first and foremostresponsibility of medical care is to treat the patient as atotal human being. Nursing students are taught basicdisciplines in the fields of social sciences andhumanities along with the major nursing courseworkand training. Courses such as sociology, psychology,philosophy and religious studies are compulsory inmany nursing programmes. Programmes such as theseare designed to produce educated humanitarianservants dedicated to the well-being of the sick anddisabled as it was originally conceived by Nightingale.When these values are being threatened by theirrational consequences of the mechanistic approach tohealth, nurses become helpless and disappointed withtheir occupations.

Nightingale revisitedWeber's analysis of the process of rationalisation inmodern industrial society predicted that scientific andtechnological progress may produce experts inscientific disciplines, but the process of rationalisationcannot produce scientifically ascertainable ideals.Therefore, scientific and technological progress,characterised by the process of rationalisation, is amixed blessing. The 'disenchantment' of the world haseliminated all mysterious and unknowableinterpretations of life by providing rational, scientificsolutions to life events. But it also usurps fundamentalvalues that assure the very survival of humanity. Theprice of scientific and technological progress is that thevalue of humanity is depreciated'. In such a system, itis conceivable that the social and economic value ofindividuals will determine who receives care. In thenarrow sense, this is a rational approach; why, after all,should more funds be expended on an individual thancan be demonstrated in terms ofhis/her social worth? Itis, however, 'irrational' in the sense that such anapproach does not take into account other aspects ofhuman life, and the basic human value that life itself isbeyond economic and social valuation.The crisis in nursing is a reflection of the attack on

fundamental values by growing instrumental rational

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Soma Hewa and Robert W Hetherington 183

systems of action - that is, the penetration of amechanistic approach into health and medicine. Thosewho cling to basic human values, such as members ofthe nursing profession, are trapped betweencompeting paradigms. The process of rationalisationde-emphasizes the ideals of the nursing professionwhich have persisted throughout history. Their workhas lost meaning under the present circumstances,largely due to the devaluation of the kind ofwork theydo in a highly technological context. This devaluationis based upon the fact that non-technologically-orientated patient-care work cannot be legitimised interms of the scientific, mechanistic paradigm whichdominates medical care today.The solution to this crisis should be based on the

health care needs of the people rather than on the basisof political struggles among competing power groups.Thus, the question one must ask is, what is the state ofhealth care needs in modern industrial societies? Giventhe present status of health in these societies, there islittle demonstrable benefit to be gained from furtherexpansion of the mechanistic paradigm (29). Thehealth care needs of the vast majority are primarily ofsuch a nature that they require services defined by anew paradigm. In this new paradigm, there must be areuniting ofthe body and the mind, but 'mind' must beexpanded to encompass social, economic and culturalaspects of human existence.The new specialists who would provide services

within this model undoubtedly will undergo a radicallydifferent type of education and orientation from thatwhich currently is stressed in medical schools.Reaching out to embrace the challenges of the newmodel will involve imagination and tolerance foruncertainty. It is a 'new way of seeing' reality, which isat the basis of the Kuhnian paradigm for scientificrevolution (30). It seems entirely likely that, under theaegis of this revolution, the nursing profession will finditself in a leadership role, given that the emphasis oftheprofession over time leads naturally towards theembracing of a more encompassing view ofhuman lifeand health.

In Weberian theory, it is predicted that socialparadigms must always be consistent with societalneeds (7). The pursuit of action within specificparadigms occurs with the blessing (legitimisation) ofsociety as a whole. Such blessing is incrementallywithdrawn, according to Weber, as overall benefits tosociety of those actions is demonstrably declining.Ongoing trends in health care needs in modernindustrial society indicate the inevitable decline of themechanistic paradigm and the equally inevitable rise toprominence of a new paradigm more suited to theneeds of the people. In the new model, there will belittle place for specialists without spirit.

Soma Hewa BA, MA, PhD is Lecturer in sociology,University ofBritish Columbia, Vancouver, Departmentof Sociology and Anthropology. Robert W HetheringtonBA, MA, PhD is Professor, Department of Sociology,

University ofAlberta, Edmonton.

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Footnote1. It should be noted, however, that in modern Westernsocieties, instrumental rational action has been used toprotect fundamental values. For example, theintroduction of Canadian and British national healthinsurance programmes has ensured every citizen of thesociety the right to receive health care regardless ofsocialclass, ethnicity, gender, religion, etc. This is a legislated(ie legal-rational) guarantee of human rights, thus aprotection of fundamental human values. Anotherexample is the institution of the Charter of Rights andFreedoms in Canada, and the Bill ofRights in the UnitedStates. These are basically examples ofthe application ofinstrumental rational action in creating rational-legalinstitutions which guarantee human values will berespected.

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