This essay will be considered primarily from the viewpoint of mental health nursing, in particular residential care offered by an NHS unit.
An ethic is a set of moral principles (Oxford English Dictionary, 1996). From the same source, the notion of moral can refer to the “goodness” or “badness” of human character or behaviour, with the distinction between right and wrong, the accepted rules and standards of human behaviour, and the ability of an action or belief to conform to accepted standards of human behaviour. Simply put, then, the notion of an ethical decision can be said to be one made according to and consistent with an existing ethic i.e., with a system of morality.
This essay will show that both the matters of morality and of ethics in health care is far from straightforward, and that therefore the position of the manager is likewise far from uncomplicated. Dawson and Butler (2003) point to background assumptions which inform ethical issues in the area of health and social care, but which have hitherto been largely neglected in the literature. Any examination of the principles which guide contemporary health and social will uncover difficulties of definition and of application (Dawson and Butler, 2003; Pattison, 2003).
Aldgate and Dimmock (2003) point out that a certain type of person invariably works in health care. Such a person obtains satisfaction from working with and for others. Dawson and Butler (2003) observe that a trustworthy person will make a trustworthy manager, a view echoed by Atkinson et. al. (2003). For some, caring is intimately related to one’s own experiences of being cared for in one’s early years (Warelow, 1996). This is however not to consider the wider aspect of what is in fact to be considered “right” and “wrong” - of what in fact it is which forms the basis upon which moral systems are constructed and ethical decisions made. Any assertion that there is a fixed morally right or a morally wrong way to deal with a situation or to make a decision is simplistic. Similarly, criteria adopted for assessing right or wrong actions can always be questioned (Jarvis, 1990). One such criterion to justify intervention in a person’s life is that it will enhance their life - though the client may not have sought this intervention, which in turn might be seen as unethical (Dawson and Butler, 2003) .
Pattison (2003) highlights the hiatus which exists within contemporary health care management whereby managers are forced to ‘fill the gaps’ left by organizational change and fragmentation in public services, a sort of “ethical vacuum” (Pattison, 2003: p.150). Atkinson et. al. (2003) point to studies which suggest that a commitment to ethics is basic to health and social work, but that such a commitment has been endangered by recent developments in health and social care which have tended to dilute it. This has to a large extent arisen because of competing pressures upon budgets and resources, which have necessitated that such decisions must be made by managers (Aldgate and Dimmock, 2003; Pattison, 2003).
Dawson and Butler (2003) advise against managers adopting ad hoc ethical systems, and they warn that ethical issues are thrown up by the very complexity of health and social care. Such ad hoc systems can be said to be provided by professional codes of conduct. The growing professionalization of managerialism (Clarke, 2003), has tended to result in separate codes of conduct for managers which though often generalized (Pattison, 2003), leave considerable scope for the manager to interpret in practice (Dawson and Butler, 2003). The morally active manager, so Dawson and Butler (2003) argue, is one who does not feel themselves to be hidebound by their code of conduct nor by notions of best practice: the morally active manager will make ethical judgements aside from these considerations. According to such a definition such an attitude might be hazardous for a nurse manager to adopt however, when perceived breaches of the Code of Conduct for Nurses and Midwives can result in deregistration (Nursing and Midwifery Council, 2002).
According to Atkinson et. al. (2003) the manager who is morally active is one who uses ethical principles in their daily practice; and this is indeed a general principle (Varcoe et. al, 2004). For Dawson and Butler (2003) the morally active manager is one who defends core or basic needs. However examination must be made of precisely what these core or basic needs actually are. Dawson and Butler (2003) point to a landmark legal case in which a perceived need was dismissed due to a lack of resources by the local authority. This is indicative of a need being perceived to be socially-constructed (i.e., only existent due to the expectations engendered by the particular level of sophistication of a society); as opposed to a need being objective (that is, a fundamental need of everybody such as food, heating, clothing, and shelter). Such a model of need is offered by Maslow (Jarvis, 1990). It could therefore be said that in this case, and depending upon one’s starting point on the hierarchy of need, the manager who denied the particular service acted ethically in freeing up resources to answer another person’s objective need; or they acted unethically in denying a need which the level of expectation created by society deems to be a valid one.
The morally active manager is one who works across agencies and co-ordinates services in the interest of his/her clients (Dawson and Butler, 2003; Health Commission, 2004). This is moral in the sense that to work in this way is often necessary in order to ensure that a client’s needs are met. An example of this occured when a client known to the service but not directly connected to the particular mental health unit, arrived on the doorstep unexpectedly claiming they were destitute. The manager acted morally in lending the client some money from petty cash and getting a member of staff who was available at that moment to accompany them to a food shop. The same manager subsequently sent a letter to the relevant Community Health Team strongly advising a reassessment of this client’s needs. It is worth noting that the professional working in the field often of necessity adopts the role of ‘street-level bureaucrat’ (Seden, 2003) which is perhaps something of a misnomer in that their decision to use resources in a certain way at ground level is really an ethical (rather than a bureaucratic) one. Such a field professional is managing resources after a fashion, and the team manager is by implication complicit in this. The manager is not in a position to take this decision themselves but to agree to it, which carries its own ethical implications: whilst the morally active manager is one who is responsible for their decisions (Dawson and Butler, 2003), there are other important ethical considerations in any choice to take responsibility for the decisions of team members working in the field.
The concept of moral activity also implies that the manager is an exemplar of how a particular ethical system is used (Atkinson et. al, 2003). This importantly stems from the manager’s role as leader, and the way in which that leadership is exercised. Being a role model - or ‘expert practitioner’ (Seden, 2003) - is an important consideration here. Many managers exercise their power in terms of the way in which the organization has defined their role (Seden, 2003); yet paradoxically this is in a manner according to the corporate ethical system. If the manager is morally active, one might expect that the way in which resources are allocated corresponds to an ethical system and if it does not, that a morally active manager therefore has an ethical responsibility to highlight the situation. The ethical system is to a large extent dependent not only upon personal and social values inculcated by the manager (Dawson and Butler, 2003), but also upon corporate expectations which are embodied by corporate policies and procedures (McDonald and Henderson, 2003). The author once worked in a private nursing home where nursing staff were directed to reuse disposable gloves which had been already been used in another clinical procedure. It could be said that in this case the manager who made this decision was acting unethically insofar as health and hygiene of residents was compromised. However, if he refused to carry out this policy (or cut his budget) bufget difficulties might force the residential home to close so putting its residents at risk. This might be an occasion to justify whistleblowing, because it can be said the manager has an ethical obligation to highlight such a practice (Ells and Dehn, 2003; McDonald and Henderson, 2003).
The medical professions work to codes of conduct which while they inform ethical practice are based upon established tradition (Dawson and Butler, 2003). This contrasts to the ethics of social care, which tend to be informed by the work of the British Idealist philosopher T.H. Green (Dawson and Butler, 2003). For Green, real freedom gives somebody the opportunity to fully realise who they are, and this can only be found in relationship with other people. By extension it is asserted that ultimately the common good is realised in the form of community (Crow and Allen, 1994; Skidmore, 1994). Green believed that the state’s function was to elevate the disadvantaged so that they are equal to others. This he felt must be done by the state regulating and enforcing basic standards of wellbeing. There have been subsequent criticisms of the nanny state (Coote, 2004), which can be seen to jeopardise the autonomy which operates as the guiding principle for social action (Dawson and Butler, 2003).
The idea of community is itself however not straightforward. Communitarianism - the insistence that human life will be improved if collective and public values guide our lives (Honderich, 1995) - is in popular political currency (Crow and Allen, 1994). One might reasonably ask whether the notion of community is an ideal to which to aspire or actually a means of offloading much of the costs of state intervention onto the family, neighbours or voluntary groups (Skidmore, 1994). A manager who is morally active will not simply allocate resources or make decisions on an ethical basis – but they will at the same time be aware of the wider picture. An example of an ethical quandary in which a manager found themselves was witnessed by the author at a meeting of service users and managers, as service managers became progressively frustrated by users who repeatedly asserted that they wanted asylum rather than their own home. Managers are obligated to see their services directed towards community provision, the thrust of a plethora of government directives (Hickey and Kipping, 1998) - and it was interesting to see users resist the allure of a certain form of community provision presented in many different ways by service managers. The dilemma for those managers came about because the same government directives and guidelines emphasise the role of users in informing and directing the development of services (Connelly and Seden, 2003), as well as implementing policies and guidelines which have placed managers uniquely in the position of managing those very services according to available resources and market splits (Waine and Henderson, 2003; Clarke, 2003). One might ask whether a manager who is morally active might simply wrestle with this dilemma, or in fact take it further ‘up the line’ by representing the interests of the users of their service in an attempt to influence government policy.
The same idealist philosophers such as Aristotle and Hegel who according to Dawson and Butler (2003) have had the greatest influence upon the development of the ethical system which informs contemporary social care also assert that the State is the arbiter of morality. All people working in mental health care operate within the struggle between benevolent care and social control (Pilgrim, 2001). To take the Mental Health Act 1983 as an example, a morally active nurse manager might ask themselves whether or not this legislation is an oppressive force or a therapeutic agent; whether or not they themselves act as guardians of the state when they restrict a client’s liberty. The Approved Social Worker is involved at the point of assessment and implementation (HMSO, 1999), but the nurse manager is involved in the monitoring and administration of the Act. The nurse manager has personal authority to detain clients under Section 5(4) of the Act. In terms of moral activity, the manager who finds themselves enforcing the detention of an individual might reasonably question how far their own (professional) autonomy and that of the individual extend in reality, since both are here defined by law. Much social care regards autonomy as the supreme guiding principle for moral action (Dawson and Butler, 2003), so the morally active manager will have cause for reflection when they implement the Act.
Another notion which comprises the goal towards which an ethical code in care work is that of ‘citizenship’ (Dawson and Butler, 2003): a service is provided to enable and empower the user to fully enter into their society and contribute to it. Citizenship is like the term community in that it has been appropriated by the government and as a result acquired a political emphasis as well as an ethical one. Whilst on the one hand this might be seen as a general movement to integrate ethical principles into British culture (Blunkett, 2002), the ethically acute manager might reasonably wonder to what ends such terms are appropriated by the State, and whether moral activity exercised in its name actually has another significance. Any ethical decisions which the manager may make are by extension also of considerable political import.
Managers have to manage competing moral demands (Atkinson et. al., 2003) caused by the pull of the situation in which they must manage resources (Pattison, 2003), and Dawson and Butler (2003) argue that it is important that the needs of individuals are considered separately from the legal and financial situation. However this can easily be considered as unethical in itself, because it is plainly not acceptable for a manager to promise a service to the client which cannot in practice be delivered to them. That is, such considerations cannot possibly be made in isolation, because considerations of legality and budget must be taken into account at the same time as any decision is made. Warelow (1996) points to the problem of caring despite circumstances or situation, and describes this as a “rule deontology” (p. 657) when the obligation of caring is the focus of a decision rather than the wider situation being taken into account.
Every individual in society is to some extent morally active, for we make decisions everyday affecting not only ourselves but also others. Applying a particular ethic requires consistency and reflection (Markkula, 2004). For Foucalt (1984), every individual action has an immediate ethical significance and is very much bound up with political impact, since any choice which we make affects those around us. For managers, the political significance is greater because decisions made can seriously affect the lives of others - whether those receiving a service, or employees. Pattison (2003) draws attention to the practice of staff appraisal, and how at the same time as such a system can be seen as ethical in that it is seeking to enhance the career of the individual worker and to refocus them upon corporate strategy, it can be seen as a highly visible form of surveillance and social control by the organization. While the morally active manager will reflect upon such a process (Dawson and Butler, 2003), it might reasonably be hoped that this reflection will alter the way in which it is approached (Pattison, 2003).
The manager is in an important position to be morally active insofar as making decisions over allocation of resources and delegation of responsibilities is concerned. In any consideration of exactly how morally active they are and how far this extends, they must consider the starting point and the origin of the ethical system which informs their decisions. Any consideration of moral activity goes much further than a brief glance at the literature suggests. The modern health care practitioner is reflective by nature of their role; and according to Atkinson et. al. (2003), such a reflective practitioner makes a morally active manager. The implication here is that the manager with practice experience is best placed to make appropriate and ethical decisions; an assertion to which Clarke (2003) alludes. Since every decision which human beings make is in fact a political one, the manager must have similar consideration for every decision which they make. It is not enough merely to account for one’s decision (Atkinson et. al., 2003); it is necessary to account for its political significance also.
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