Column

It’s time these codes were broken

The Code of Practice at Autumn Leaves Rest Home says:

‘It is the responsibility of nursing home management to ensure that the privacy and dignity of residents are respected.’

Yet everyday the elderly ‘guests’ are compelled to leave their bedrooms to sit in the dayroom, where the TV is continuously on.

The New Zealand Medical Association Code of Ethics tells doctors to:

‘Exchange such information with patients as is necessary for them to make informed choices where alternatives exist...’

Yet in the local intensive care unit families are routinely consulted before and even instead of competent patients, experimental techniques are carried out without permission, and teaching is undertaken secretly.

Code after code says:

‘...consider the health and well-being of your patients to be your first priority and act in their best interest...’

Yet staff rarely if ever meet to discuss what promoting ‘health’, ‘well-being’ and ‘best interests’ might imply.

Everything is OK. All health professionals have ethical codes. Yet everything is not OK. Why?

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The UKCC Guidelines for Professional Practice say nursing codes of ethics are supposed to:

‘... help (nurses) reflect on the many challenges that face us in day-to-day practice’ (Function A);

‘... provide principles to aid (nurses’) decision making’ (Function B);

‘... present important themes and principles which you (nurses) must apply to all areas of your work’ (Function C).

However, there are obvious differences between these functions. For example, whether a code’s statements are said to be aids (Function B) or principles which (nurses) must apply to all areas of (their) work (Function C) is no small matter. Aids may be used or not, rules are meant to be obeyed. But the UKCC neither explains which function practitioners are supposed to follow, nor how they are to decide between functions in different contexts.

As with all codes of practice, the problem is this: if they are not to be treatises of moral philosophy, they must be short. Brief statements meant to cover all circumstances are bound to be vague. Vague statements are open to interpretation. Once interpreted, the codes fall away – it is no longer the principles but how they are understood that matters, and the possible interpretations are almost endless.

And so we are left with parallel health realities. There is the fantastically pristine world of the codes, where everyone and everything is ethical, and there is a deeply ingrained health service culture governed by (and therefore for) the health professionals who inhabit it.

Codes of practice are not in patients’ interests. They are not laws, so there can be no appeal to open court. They do not promote intelligent reflection in health professionals, in fact they inhibit it. Consequently they reduce the chances of the guardians of health service resources engaging in reasoned discussion, either among themselves or with patients.

In the unlikely event of our being offered a choice between ethical fantasy and direct accountability we should ban codes of practice, since the only thing they protect is the status quo. They should be replaced with compulsory in-service training in ethical analysis for all health professionals, and regular open meetings at which health professionals must explain their philosophies and practical choices to any member of thepublic who cares to attend.