Intended for healthcare professionals

Education And Debate

An Ethical Dilemma: Commentary: Disciplinary processes should not be used to solve ethical problems

BMJ 1996; 313 doi: (Published 16 November 1996) Cite this as: BMJ 1996;313:1251
  1. Jackie Short, senior registrar in forensic psychiatrya,
  2. Gwen Adshead, lecturer in forensic psychiatryb
  1. a Wallingford Clinic, Fairmile Hospital, Oxfordshire
  2. b Institute of Psychiatry, London SE5 8AF

    The report suggests that managerially, it was apparently “wrong” for the nurse to deceive the patient (which justified the final warning) but not “wrong” for the doctor to have ordered the deception. This suggests that the ethical duties of doctors and nurses are perceived as different. However, it seems hard to argue that nurses should be more honest than doctors in their clinical practice unless it is important to protect a tradition of strong medical paternalism.

    The author also raises concerns about a style of nursing management. Some of these concerns are not peculiar to nursing: the comparative inexperience of managers, younger managers managing older staff, the possible influences of sexual and ethnic prejudice. In nursing, there may be particular concerns about how nursing autonomy is protected or promoted within multidisciplinary teams. For example, in the first and third paragraphs, the author refers to the nurse “obeying” the consultant, as if the nurse were a slave of the medical hierarchy. But the United Kingdom Central Council for Nursing, Midwifery, and Health Visiting guidelines state clearly that nursing staff can conscientiously object to actions with which they disagree.1

    Trials of war criminals have made it clear that obedience to an order is not a complete excuse for illegal or immoral behaviour. Nurses do not “have” to “obey” any instruction given, even by consultants. Why didn't the consultant give the patient his tea?

    The reality is that the nurse and the doctor agreed on a course of clinical action, which others seem to have deemed ethically “unacceptable.” What seems clear is that the disciplinary process was (and is) a bad way to resolve ethical disputes. This could have been an opportunity for the whole team (and others) to learn and develop their skills in analysing ethical problems. Instead, the message seems to be that if you do something that someone else thinks is ethically “wrong” you could get suspended, unless you are a doctor.

    The disciplinary process described seems bizarre. Two professionals ethically do the same thing (deception); one gets suspended, warned, and required to “retrain” (in what?—assertiveness skills with doctors?) while the other is “invited” to talk to the unit general manager, disciplined, and exonerated. It might be said that this simply reflects the different status of the two professional groups; but a difference in status does not imply a moral difference. In an ideal world, princes and paupers get the same justice.

    If decisions are going to be taken by multidisciplinary teams, it seems appropriate that disciplinary procedures are themselves multidisciplinary. The doctor and the nurse could have been seen together by a team comprising a nurse, a doctor, and one other professional. This would improve cohesion of teams, foster trust, and reduce the risk of people being used as scapegoats. However, in the present paranoid climate use of scapegoats is so convenient that it is unlikely that any organisation will try to eliminate it.


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