Volume 1, Issue 02 - April 1998

Relational Ethics. What is it?

"Ethical behaviour is not the display of one's moral rectitude in times of crisis," says nurse Myra Levine, "It is the day-to-day expression of one's commitment to other persons and the ways in which human beings relate to one another in their daily interactions.1

Guest Writer Profile:
Vangie Bergum, RN, PhD

This month we are very pleased to have as our guest writer, Dr. Vangie Bergum.

Vangie Bergum, a native of Alberta, has been affiliated with the Bioethics Centre, University of Alberta since 1988. She is Co-Director of the John Dossetor Health Ethics Centre and Professor, Faculty of Nursing, University of Alberta.

Her interest in healthcare ethics developed from her work in community health, with particular interest in childbirth education. Her research program in ethics began with her research on the experience of becoming a mother, with her doctoral research published as Woman to Mother: A Transformation. This original research led to further study of women who become mothers through adopting and in placing their babies for adoptions. She is principal investigator of an ongoing Relational Ethics research project involving 18 scholars and healthcare professionals from a wide variety of disciplins. The group has produced a video, is preparing a book, and plans to develop interactive texts on the world wide web.

Dr. Bergum is also active in her role as educator and has been establihing interdisciplinary courses in healthcare ethics at the graduate and undergraduate level.

"The Chinese character for acupuncture means golden needles. For me," says physician Dr. Steven Aung, "this symbolizes that the needle is only a bridge between myself and my patients. It is a bridge built on compassion and the cultivations of physical, mental and spiritual energy. This is what does the healingnot the needle. The really important thing is the relationship of trust and respect between healer and patient."2 It is the business of caregivers to explore the reasons, and even argue, with patients about the decisions they wish to make because, says lawyer Robert Burt, people are connected to each other. Caregivers (doctors, nurses, and others) are human beings who are necessarily involved in another's life, so, "we have to negotiate together what our shared meanings are about, what it is that you want me to do or not to do." In fact, says Burt, "it is correct not only for me to say, 'Why do you want to do that?' but it is permissible for me argue with you if I disagree, and to argue strenuously with you on a variety of grounds."3

Myra Levine, Steven Aung, and Robert Burt point to an ethic of relationshipsthat striving to make connections with people, through trust and respect, in order to express compassion in giving the necessary care and treatment. Relational ethics means initiating and maintaining conversation, and it means that ethics is found in the day-to-day obligations and responses to one another.

I have come think of relational ethics as having four central concepts: 1) ethics is "how" we treat each other while clinical concerns attend to the "why" of a particular treatment; 2) ethical action is reciprocal (that is, providers and recipients both give and both receive); 3) personhood (autonomy) is developed and expressed through connections between people rather than through individual rights; and 4) ethics is the question "what should I do now?" rather than the statement "this is what you should do now." As action ethics, relational ethics looks to the way we are with each other as doctors, patients, nurses, families, or chaplains. We are participants by being with rather than merely spectators who only observe, advise, or treat.

Relational ethics builds on the premise that "human experience is, in principle, shared experience" which leads us to understand ourselves, as persons, not as an 'I' but as a 'You and I', wrote the philosopher John Macmurray in 1961.4 "It is an illusion that we are individuals, isolated individuals," says a member of the Relational Ethics Research Project, "we are made of the same stuff. We were social when we were born. I mean, we were born of a woman, our origins are social. If we could only see in ourselves that we are bits of everybody it would be easier."5 Relational ethics attends to those connections that bind us together as humans.

Perhaps we could say that with relational ethics we focus on "who we are" rather than "what we do," that it is a way of being rather than a mode of decision making.6 It is how we insert a needle, how we enter into conversation, how we show respect, or how we are with each other. Knowledge of ethical theories and principles are vital in this conception of ethics, yet such knowledge, alone, is not sufficient for ethical practice. In working from a relational ethic one would not be content watching a person die after making a fully competent choice to forgo treatment; rather it would be important to be with the dying person.

For the last five years, an interdisciplinary group of healthcare professionals and academics have been involved in a research project called Relational Ethics. Foundation for Health Care. This research is funded by the Social Sciences and Humanities Research Council of Canada (1993-2000). In this research, we want to develop an ethic for health care that parallels the rich complexity of actual human relations and to recognize and build on the moral significance of these relationships.7 The interdisciplinary research team focuses on concrete experiences (healthcare scenarios) in order to develop a comprehensive practical understanding of ethical commitments. Our goals are to describe ethical relationships through exploring themes identified through the research process: engaged interaction, mutual respect, embodiment (embodied knowledge), uncertainty or vulnerability, freedom and choice, and the significance of the environment. These themes are being developed into a text entitled Relational Ethics. The Full Meaning of Respect which we plan to have available within the next year.

Early on in the research project we realized that words may not necessarily be the best way to describe the experience of relational ethics so we began to explore other approaches. We gathered personal stories or narratives, images (developed a slide series called "Is this Ethics?"), and drama (wrote, acted, and produced a video called "and, they want a child.") Narratives, images, and drama have great potential to teach about ourselves and the nature of healthcare work, to sharpen visual senses, generate new insights and understandings, and to promote ethical awareness.8 In a relational ethic both the heart and the mind must be stimulated as neither mind nor emotion alone is adequate.

In reality, relational ethics is already practised in health care: in the thoughtful way we treat students and colleagues, the way we welcome babies and comfort elders, the way we express compassion to both the suffering of patients and families and the suffering of providers who are faced regularly with human tragedies, and so on. The goal in the research is to articulate this relational perspective in a comprehensive and philosophically well grounded way which includes and extends traditional ethical theories. The objective is to turn thinking about ethics and our ethical commitments to the reality of how and where we experience them within health care practice.

Please consider this brief document as a working draft, one in which you are welcome to add your voice. Please contact Sandy MacPhail, Project Director, or Vangie Bergum, Principal Investigator at the John Dossetor Health Ethics Centre (492-6676) with any comments you wish to contribute.


References

1Levine, Myra. (1977). Nursing ethics and the ethical nurse. American Journal of Nursing, 77:5, p. 846.
2Aung, Steven. (1998). Golden needles of compassion and competence. Feel Good Magazine, 3:4, p. 8.
3Burt, Robert and Cowart, Dax. (1998). Confronting Death. Who Chooses? Who Controls? Hastings Center Report, 28:1, p.15.
4Macmurray, John. (1961). Persons in Relation. Volume 11 of the Form of the Personal. London: Farber & Farber, p. 61
5Taken from a transcript of the interdisciplinary research group meetings.
6Tarzian, Anita. (1998). Breathing lessons. An exploration of caregiver experiences with dying patients who have air hunger. Unpublished doctoral dissertation. University of Maryland.
7 Sherwin, Susan. (1992). No longer patient. Feminist ethics and health care. Philadelphia PA: Temple University.
8Darybyshire, Philip. (1993). Understanding caring through photography. In Diekelmann, NL & Rather, ML. (Eds.). (pp 275-290) Transforming RN education. Dialogue and debate. NY: NLN Press.

Vangie Bergum, Co-Director, interim, John Dossetor Health Ethics Centre

 

Announcements

  • The 10th Annual Canadian Bioethics Society Meeting will be held in Toronto, Canada on October 15th-18th, 1998. The conference is hosted by the University of Toronto Joint Centre for Bioethics. Confirmed plenary speakers include James Childress, John Lantos, Robert Levine, Laura Purdy, and Judith Wilson Ross. For more information please contact (416) 478-1906 or see the CBS website at www.bioethics.ca.
  • A reminder that PHEN has created a user fund to provide grants of up to $500 to Network members wishing to attend conferences or undertake educational projects to enhance their awareness of health ethics issues. For information on how to apply for this award, please contact the Edmonton office at (800) 472 - 4066. Application Deadlines for the fund are May 1, September 1 and November15, 1998.
  • PHEN is in the process of compiling a listing of resource people and others interested in networking on health ethics issues. The deadline for submission of forms to be included in the Health Ethics Resource Directory has been extended until May 11, 1998. Anyone wishing to submit or obtain a form, or requiring further information on this project, please contact Rachel at PHEN's Southern Alberta office or via email at lynch@phen.ab.ca.
  • PHEN has been in discussion with the Calgary Herald about submitting articles on ethical issues that are relevant to rends in health and health care. If you would be interested in writing an article, please contact Al-Noor at nathoo@phen.ab.ca.
  • A reminder that this space can be made available to advertise your upcoming event.

 Administrative Changes at PHEN:

  • PHEN's Northern Alberta Coordinator, Gail Poole, has left her position for the greener pastures of Vancouver.
  • The Director of PHEN, Dr. John Dossetor, will be leaving his position as of May 9, 1998. He will be moving this summer to Ottawa where he will be closer to his family and able to spend more time with his 7 grandchildren.
  • Southern Alberta Coordinator, Al-Noor Nathoo, will function as Acting Director until a permanent Director is appointed. More information about this position can be obtained at our website.
  • Because of space limitations, PHEN's Southern Alberta office, presently in Room 37, Heritage Medical Research Building Calgary, will be moving on May 15. If you are aware of any small empty office space that may be available in the Calgary area, kindly contact the PHEN office. We would like to thank Dr. Doug Kinsella, Director, as well as the staff of the Office of Medical Bioethics, U of C, for their contribution of space and facilities to PHEN over the past two years.

 

Other News

Issues and Prospects for Canada's Health Care System
Free Public Lecture
Sheraton Cavalier Hotel Calgary, Friday May 8, 7:00 - 9:00 PM, Reception to follow

Dr. Tom Noseworthy, Professor and Chair of the Department of Public Health Sciences, Faculty of Medicine and Oral Health Sciences, University of Alberta, and member of the former National Forum on Health, will launch PHEN's Third AGM and Provincial Workshop to be held in Calgary on May 8 & 9, 1998. Dr. Noseworthy's lecture is a free public session.

The AGM & Workshop is entitled Strengthening the Moral Foundations of Health Care, and will be of interest to members of ethics committees and other service providers/members of the general public with an interest in Alberta health ethics issues. Full details on our web site.

 

Questions or comments about this publication are welcome and can be directed to either PHEN office. Please feel free to copy and distribute this document.

 

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.