highly? Is her own happiness paramount? Or is it crucial that the patients on her
ward get the best possible service? If the latter, does it matter that if she succeeds in
getting what she wants for her ward, resources may be moved from other hard-
pressed parts of the hospital ± so decreasing the quality of service to other patients?
If she finally decides that thecontextis simply unacceptable, and that something
must be done to improve it, then `doing the right thing 1' may very well cease to be
an option.
8.15 Principled solutions?
Some nurses may find it helpful to try to apply ethical principles' to resource allocation dilemmas. This approach has been widely recommended in recent years, and most texts onnursing ethics' contain sizeable sections on basic', ethical' or philosophical' principles [8]. A quartet of principles are regularly advocated, and it is likely that most nurses will at least have heard of them. They are :non-maleficence' !do no harm), beneficence' !do good),respect autonomy'
!respect the patient's choice), and justice' [9]. !See Chapter 2.) The attraction of this group of principles is that they seem to offer an uncomplicated structure within which to organise one's thoughts. Moreover, it seems possible to seize on just one of these principles in order tosolve' a dilemma. If, for instance, a nurse
feels that a doctor is not taking the wishes of a patient seriously she might describe
this as unethical' behaviour purely because the doctor is notrespecting auton-
omy' !so ignoring or overriding any alternative justifications the medic might
have). Most nurses will have personal experience of cases in which this has hap-
pened ± and might well consider it fair criticism ± but it is very important not to
confuse the assertion of single principles !however justifiable) with ethical ana- lysis'. The latter is a much more complicated procedure which ± if it is to be done at all properly ± must involve reflection upon a range ofethical principles' together
with the other considerations !context,outcomes,obligations)already mentioned in
this section.
This is not to say that the use of the principles is unhelpful. The point is that any
thoughtful ethical analysis is bound to place considerable intellectual demands on
the health care analyst. In Case two it might appear that the hub of the matter is a
straightforward clash between the ideal of efficiency' and the principles ofjustice'.
It might, in other words, seem to nurse W that her patients are being unjustly
treated, and that their interests are regarded as secondary to those of the hospital
as a whole !which must be run as efficiently' as possible). However, if W is seriously to argue this case then it is not enough for her merely to cryunjust!' since
justice' can be understood in more than one way, and can even be interpreted in ways which contradict each other. For example, there are those who think that the key to understandingjustice' is
to treat people first and foremostin accord with what they deserve;others disagree,
arguing that the basic criterion of justice isneed;and there is a further group who
believe that justice can come about only when people'srightsare upheld [10]. What
is more, sophisticated analysts tend to blend and adapt these different
understandings in subtle ways, depending on the matter under scrutiny. Any
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