Cyfarchion o Gymru Gwlad fy Nhadau

Why doing “The Greatest Good for the Greatest Number” may not be the right thing to do: the complex moral landscape of disaster nursing Jeff Evans RN, Bnurs, MSc, PGCertEd, SFHEA Award Leader, MSc Disaster Healthcare, Senior Lecturer Disaster Healthcare, School of care Sciences, University of South Wales. 6th September 2018 © University of South Wales

Outline The moral landscape of nursing Disasters ‘the greatest good for the one’ Disasters The ethical reality of nursing in a disaster Nursing ethics in disasters ‘the greatest good for the many’ Alternative views

The moral landscape of nursing Focus on the nurse and their client The greatest good for the one Preferences the present over the future Explicit in codes of practice and published codes of professional ethics Reasons Action guiding Action justifying

Disasters Pragmatic declarations Evaluative Exceptions “A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources” ICN Framework of Disaster Nursing Competencies 10 or more people reported killed; 100 or more people reported affected; declaration of a state of emergency; call for international assistance. EM-DAT Evaluative Exceptions

From a nursing perspective, disasters are essentially ethical events

Ethical world of disaster nursing Overwhelming need and insufficient response resources Prioritisation & rationing Playing God over life and death Nurse as author of another’s suffering Balancing own needs with the needs of others Own needs Self-sacrifice Social obligations Personal endeavours and projects Doing bad things to get good results Allowing harm to achieve a greater good Doing harm in order to achieve a greater good

Achieve the greatest good for the greatest number Consequentialist Future orientated Needs of the many over the needs of the one Compatible with common sense Action guidance Justification to self and others Difficult to operationalise What is the ‘good’? Who are the ‘greatest number’? Information and rationality Forgives too much Demands too much

Alternatives to consequentialist ethics

Rights, obligations and duties -deontology Moral duties just because they are the right thing to do Rights based approach Codes of practice “The nurse practices with … respect for the inherent dignity … of every person” Code of Nursing Ethics ANA Does not help when obligations collide Incompatible ‘oughts’ Regret, guilt and moral distress Moral residue Signature of disasters

What is left? Disaster settings work against consequence based ethics Moral dilemmas in disasters point to the problem of irreconcilable ‘oughts’ The only point of certainty is the nurse and her decisions The nurse as moral agent

The nurse as moral agent Virtuous practitioner Prudence Justice Courage Temperance Interpersonal relationship virtues Compassion, honesty, patience Respect for the person Moral wisdom Virtue permissive care environment

Concluding remarks We should re cast our approach to ethics in disasters to focus on the nurse as moral agent Disaster preparation should develop the virtuous practitioner Managers and disaster planners should seek to create virtue- enabling care environments

Any questions?