Moral silence? : nurses' experience of ethical decision making at the end of life
The ethics literature to date has suffered from an inadequate empirical base on which to support discussion about practice, policy and education. Research in the area of ethical decision-making has been inconclusive because of unclear conceptualisations of moral problems, and different methods to investigate the extent to which nurses are confronted with them. In particular, the contextual influences on the formation of moral conflicts and nurses' responses to them have not been explored. In cancer care, there is anecdotal evidence that such influences have a powerful effect on the interaction between individual nurses and perceived moral problems. The study aims to redress previous inadequacies by exploring individual nurses' engagement with perceived moral problems as they occur on an acute cancer unit. The surrounding influences and effects on patient care are studied as part of a fieldwork analysis involving 18 months of participant observation. The researcher worked alongside individual nurses in order to deepen understanding of their perception of moral conflicts. Findings involve the central concern that ethical decisions are not made, and that this can, in part, be attributed to nurses' evident pattern of emotional distancing. The function of emotion in enabling moral engagement is a central argument of this thesis. The lack of a credible ethical language in practice and the effects of hierarchical decision-making are also explored. Against a backdrop of the frequently mismanaged border between acute and palliative care, these issues appear to combine to leave patients and their relatives unsupported as death approaches. By studying ethical decision-making in the context of its application, this study can reliably suggest ways forward in practice. The implications are far-reaching and offer recommendations which improve on those contained in recent policy literature. They will be of direct relevance to those involved in pre- and post registration, and to those responsible for acute cancer services in the UK.