well-being; someone's well-being may be increased by a tour of the Mediterranean,
by acquiring a new friend ,or by learning Latin. None of these things ,nor many
others like them ,seem to be the function of nursing. So perhaps it would be better
to say that nursing is about the promotion of certain elements of well-being. One
version of this ,for example ,is to equate nursing with the promotion of health. This
is only an improvement if we can give a meaning to health which is less all-
encompassing than well-being ,and yet less narrow than the idea of absence of
disease ,which fails to capture all of the work of nurses. A number of authors have
advocated such a middle-order' conception of health ,with the intention that such aconception would help clarify the central objectives and priorities of health workers [4 ,5]. Broadly speaking these conceptions identify health with what others would callwelfare' ,i.e. someone is healthy to the extent that they have the
resources to pursue and achieve well-being or fulfilment. In practical terms this
would mean that nursing is about helping to ensure that individuals are in a
position to travel ,or to learn languages etc. This is not the place to review all of the
discussions that have taken place on the theme. But it is possible to make a few
comments on the central issues.
Although it is useful to try and clarify the aims of nursing there is no reason to
suppose that a single phrase or formula will capture everything which nurses aim
at. It is reasonable to assert that the central or overall aim of nursing is to con-
tribute to welfare ,but this simple formula needs to be qualified otherwise it is
arguably both too broad and too narrow. First ,the way in which welfare is pro-
moted is ,in the main ,based around the management 6including prevention) of
suffering or risk rather than wider aspects of welfare promotion such as financial
assistance or education ,although there is a place for these within health care. That
is to say that nurses rightly do not regard the promotion of all aspects of all
people's welfare as within their remit. They respond to the suffering of individuals,
or to the risks faced by certain populations. Second ,once in a relationship with a
client they need to have regard to all aspects of well-being that might be relevant to
caring for that person. This is part of what is meant by holistic care ,but it also
follows from a concern with the promotion of welfare; for how can you know
whether you are contributing to someone's welfare if you do not see what you do in
the context of their whole life? Only by having regard to the whole can nurses
ensure that their work is in the interest of their clients.
It is not possible to promote welfare ,for example ,without having regard to both
the costs and the benefits of proposed interventions. Any intervention is likely to
have some `cost' or risk for the client which has to be weighed against the expected
benefit; and there will be wider costs and benefits for others affected directly or
indirectly. 6We will return to this below.) Neither can welfare be promoted without
having regard to the wishes or preferences of clients. This is because an important
part of my welfare consists in having my wishes respected. So even if a nurse is
clear about her aims ,and has a clear view of what is in the interest of her client ,she
faces a number of potential problems of fundamental importance. What if the
client disagrees about what is in his or her interest? What if the client agrees that in
some respects the nurse's preferred intervention is in his or her interest but for
some reason does not wish the intervention to take place? What if the client is not
in a position to express an opinion? Under all of these sets of circumstances an
TheEthicalDimension 21