Archive for the ‘Rosemarie Rizzo Parse’ Category

Autonomy and the Nursing Role

September 20, 2010

In health care ethics, autonomy has primarily been conceptualized in the context of physician-patient relationships.  The central ethical concerns have revolved around paternalism and issues of consent.  Thinking of autonomy as the capacity for informed consent, including lack of coercion and capacity for effective deliberation is a relatively “thin” conception.  It attributes to the patient just enough moral status to block paternalistic intervention. More recent work has developed a “thicker” notion of autonomy.  These authors have embedded the key moral dimensions of autonomy in a more psychologically realistic picture.  The resulting conception of autonomy helps us sort out the sticky cases of diminished capacity (both temporary and progressive), and distinguish “authentic” choices from those made under the emotional pressure of a moment.  While these developments in the literature are both philosophically interesting and practically useful for health care professionals, they continue to focus on patient choice of treatment as the paradigmatic context in which autonomy is manifest.  The vivid cases discussed in the literature are major interventions for life threatening conditions, not mundane choices like whether and how to follow a prescribed treatment for psoriasis.  The physician’s perspective dominates this literature.  Physicians provide treatment options in a way that nurses cannot; and a nurse’s relationship with the patient takes place within the context of those larger decisions.  Nurses thus have a different perspective on patient action, deliberation, and choice.  Does this difference make a difference for the way in which we should conceptualize autonomy?

A traditional conceptualization of nursing emphasized the role of the nurse in helping the patient achieve something s/he could not do alone.  For Weidenbach, this was the “need-for-help,” and for Orem is was the “self-care deficit.”

Parse and her followers have argued against that traditional conceptualization of the nursing role.  They think that the patient should be unconditionally (existentially) free to define health for him or herself.  the emphasis is on choices, not capacities.

Doesn’t this model realign the concept of autonomy with the physician’s perspective?

Reductionism and Holism: the Practical Holism of Nursing Practice (Part 3)

December 29, 2009

Holism and Reductionism in Nursing

In two previous posts, I have explored some of the meanings of “reductionism” and “holism” found in the philosophical literature (see Reductionism and Holism: Three Varieties (Part 1) and Reductionism and Holism: Ontological (Part 2)). While these conceptions of holism and reductionism have been influential in the nursing literatures, they do not exhaust the uses of the terms “holism” and “reductionism.” Indeed, there is a use of “holism” in nursing that seems to fit neither the epistemological nor the ontological senses of the term. It is nicely illustrated in the following passage from Rosemary Ellis’s “Characteristics of Significant Theories” (Nursing Research 17 (3): 217-222):

Holism, if used as the appropriate view for aiding a patient, requires that one be concerned with any factor, be it physiological, social or any other, which affects the patient’s health. It requires that the factors be treated in combination, not in isolation. It also means that the combination is not the same as the sum over each factor. Nursing requires the recognition of the inseparability and interdependence of many factors. (p. 218)

What conception of holism is embedded in this text?

Practical Holism

The first point to notice is that the topic—that about which one is to be holist or reductionist—is not theory; it is practice. This means that Ellis is not expressing epistemological holism. That is, she is not taking position on how theories are related (e.g. whether sociology might reduce to biology, for instance). Nor does she seem to be taking a position on what exists (at least not directly, more on this below). Holism, according to Ellis, is something that might be “the appropriate view for aiding a patient,” and it requires a specific kind of concern. It is a practical commitment to treat the factors influencing a patient’s health in combination.
The “reductionism” that Ellis implicitly opposes is found in medicine. Physicians were portrayed in this period (and often since) as narrowly concerned with the patient’s disease or dysfunction. (Whether this is an accurate portrayal is an open question.) The nurse, by contrast, was charged with a broad responsibility for the patient and his or her environment. A reductionist approach in this domain would consider a patient’s disease or dysfunction in abstraction from the other factors. Because of her role in health care, a nurse cannot be so limited.

The broad responsibility of a nurse is the source of the idea that nursing is committed to holism. The nursing role demands that a nurse attend to any and all factors that affect a patient’s health. To limit nursing concern to one organ system, or to one dimension of psychological or social dysfunction, would be to ignore the broader context of patient health which has been central to nursing since Nightingale’s time.

Practical holism, then, is the commitment to address the whole of a patient’s health. Each of the many factors that affect a person’s wellness needs attention, and they must be attended to in a way that recognizes the interactions among them.

Ontological implications

Practical holism is different from epistemological and ontological holism. But what are its implications? Does practical holism entail strong (or weak) forms of ontological or epistemological holism?

Arguably, practical holism is inconsistent with strong forms of ontological holism. A strong ontological holist about minds, for instance, holds that the existence of minds is independent from the existence of bodies. The mind and body are causally linked, to be sure, but the connections are contingent. Changes in the nervous system need have no affect on the mind. Ironically, ontological holism about the mind supports a kind of reductionism in the practical realm. An intervention might target the mind alone without consideration of the body, for after all, they are independent.

In the nursing literature there are some very strong commitments to ontological holism – in the work of Rogers or Parse, for instance. If the foregoing arguments are correct, then the metaphysical views of Rogers or Parse are incompatible with the nursing commitment to address the whole patient.

Practical holism, Ellis says, “means that the combination is not the same as the sum over each factor.” This suggests that the mind and body (to continue the example) should be understood as interactive. They are not two ontological kinds linked by contingent inputs and outputs, rather, they are aspects of the same reality. The moderate holism of the gate control theory of pain (see Reductionism and Holism: Ontological for a brief discussion) is much better suited to the commitments of practical holism. Nursing interventions need to consider the physiological, psychological, and social dimensions of pain in combination. If these “factors” are conceptualized in a unified way—pain is both something experienced and a physical phenomenon—it will be natural to design interventions that are not merely a “sum over each factor.”

Conclusion: Nursing and the Three Varieties of Holism

Nurse scholars often characterize their discipline by a commitment to holism. This commitment is sometimes used as a basis for rejecting certain kinds of research as not properly part of nursing science. Causal models of biological, psychological, or social systems are often marginalized for this reason. The foregoing discussion provides a new perspective on such claims.

A commitment to practical holism is a consequence of a traditional conception of the nursing role. If nurses are charged with attending to the full gambit of patient needs, then nurses are committed to the whole patient. They could not be reductionist in the sense of attending to just one factor affecting health. Practical holism, then, is arguably central to nursing practice. Epistemological and ontological holisms are not similarly implied by nursing practice, and therefore they are not central to the nursing discipline.

It is plausible to reject causal models because they conflict with the holism only if one conflates the different varieties. Once the varieties are distinguished, we can appreciate some of the subtle relationships among them. The moderate ontological holism of the gate control theory of pain, for example, is more compatible with the practical holism of nursing than the strong holism of Rogers or Parse. Far from being marginal to the nursing discipline, some kinds of mechanistic causal modeling might be central to it.