Nursing Law and Ethics

can do something to change things for the better. If, for example, she decides not
only to treat V !in Case one) but to publicise the fact in local newspapers !so both
promoting the hospital as a compassionate organisation and letting it be known
that were funds available an accident and emergency service could be provided or
reinstated) then she might have an impact. Moreover, if the nurse were to contact
the relatives of the patient who died in distressing circumstances' !in Case two) and enlist their support she might campaign intelligently and effectively for more resources. On both strategies she would face very significant risks ± indeed she could expect censure from the system were her involvement to become known ± but she would at least stand a chance of making a desirable difference. She would, in other words, be working for justice as a combination of meeting needs, deserts and upholding rights ± through positively discriminating in favour of those patients closest to her. In general, a great deal rests on the following question, and how it is answered in the coming years :whether nurses in general continue mostly or onlyto do the
right thing 1' or whether the profession increasingly aims to do the right thing 2' !and commits its own resources to ensuring this). If the former, then it is hard to see how nurses will be able to justify their claim to professional status, but if the latter, and the majority of nurses become able and willing to think through the questionHow best might I act in this situation?' !rather than ask What am I supposedto do here?') then nurses, as a group, might perform an enormous service: they might open up the health service to internal debate, to genuine conversation !without fear of sanction and reprisal) about how best to deliver public health services ± not least when there are not enough of them to go round. And it is certain that it is only by continually considering whetherto do the right thing 1' or
to do the right thing 2' that nurses will exercise theirmoral muscles' sufficiently to
effect resource allocation injustices for the better, since never to consider `doing
the right thing 2' eventually and inevitably destroys the capacity for moral
reasoning [11] [12].

8.17 Notes and references

1. SeeHealth Care Analysis1993; 1 !1)passim.


2. Williams, A. !1992) Cost-effectiveness analysis :is it ethical?Journal of Medical Ethics,
   18, pp. 7±11.


3. Harris, J. !1991) Unprincipled QALYs :a response to Cubbon.Journal of Medical Ethics,
   17, pp. 185±8.


4. Hackler, C. !1993) Health Care Reform in the United States.Health Care Analysis, 1 !1),
   5±13.


5. Smith, A. !1987) Qualms about QALYs.The Lancet,1X34±36.


6. Seedhouse, D.F. !1994)Fortress NHS: A Philosophical Review of the National Health
   Service.John Wiley and Sons, Chichester.


7. Culyer, A. !1992) The morality of efficiency in health care ± some uncomfortable
   implications.Health Economics, 1 !1) p. 7±18.


8. Thompson, I., Melia, K.M. & Boyd, K.M. !1988)Nursing Ethics,Churchill Livingstone,
   Edinburgh.


9. Gillon, R.P. !1985)Philosophical Medical Ethics.John Wiley and Sons, Chichester.

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