95 日本看護倫理学会誌 VOL.7 NO.1 2015 ■ 日本看護倫理学会第7 回年次大会 基調講演 看護倫理における尊厳の意味、 その発展の経緯と看護者に与える影響 The role of dignity in nursing ethics: what it means; how it has evolved; and why it matters to nurse practitioners Professor Ann Gallagher ◉University of Surrey, UK & Editor, Nursing Ethics (監訳:太田勝正 名古屋大学大学院医学系研究科) 1. はじめに まず最初に、年次大会の講演の機会にお招きいただ きましたことに対し、日本看護倫理学会の太田教授、 小西教授、会員の皆様にお礼を申し上げます。日本を 訪問し、日本の方々や日本のすばらしい文化、文学、 および哲学の伝統から学べることは常に大きな喜びで す。 看護における尊厳をテーマにした会議というものは 極めて重要であり、患者、実践者および看護専門職の 尊厳をどのように理解すればよいのかを、ともに議論 する機会となります。また、患者、家族、同僚と接す る仕事において、どのように尊厳を高めていくのか、 どうしたら、尊厳を損なうのではなく高められる医療 の実践や組織となれるのかを理解する必要もありま す。 近年、医療における尊厳に大きな注目が集まってい ます。悲しいことに、これはケアの現場において尊厳 が無視され、患者が放置、軽視、時には虐待されてい たという報道がなされたことが主な理由です。 看護倫理の国際ジャーナル、Nursing Ethics で、 尊厳に関する最初の論文が掲載されたのは、1998 年 のことでした。それ以来、20 件以上の論文が掲載さ れ、また2013 年にDagfin Naden により特別オンライ ン版も編集されています。この尊厳というトピックに ついてはさらに多くの論文が他の専門誌や書籍で掲載 されています。なかには、尊厳とは、「無駄」で「愚か な」概念であると主張するものもあります。 私は、尊厳は無駄でもなければ愚かでもないと皆様 に訴えたいのです。それどころか、尊厳は看護倫理の 本質的な価値であり、それ以上のものであると主張し たいと思います。尊厳とは、第一の価値であり、そこ Introduction I would like to begin by thanking Professor Ota, Professor Konishi and colleagues in the Japanese Nursing Ethics Association for the invitation speak at this conference. It is always a great pleasure to visit Japan and to learn from its people and very fine cultural, literary and philosophical traditions. A conference on the theme of dignity in care is very important and gives us the opportunity to discuss to- gether how we might understand the dignity of pa- tients, of practitioners and of the nursing profession. We also need to understand how we promote dignity in our work with patients, families and colleagues and how we can have healthcare practices and orga- nizations that promote rather than diminish dignity. There has been a great deal of attention to digni- ty in health care in recent years. Sadly, this seems mostly due to reports of indignity in care contexts where patients have been neglected, disrespected and sometimes, abused. The first article on dignity appeared in the jour- nal Nursing Ethics in 1998. Since then we have had over 20 articles in the journal Nursing Ethics with a special online issue edited by Dagfin Nåden and colleagues in 2013. There are also many more arti- cles in other journals and books on this topic, in- cluding some that have argued that dignity is a ‘useless’ or ‘stupid’ concept. I hope to persuade you that dignity is neither useless nor stupid. I will argue that dignity is, on the contrary, a core value in nursing ethics. And it
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95日本看護倫理学会誌 VOL.7 NO.1 2015
■ 日本看護倫理学会第7回年次大会
基調講演
看護倫理における尊厳の意味、 その発展の経緯と看護者に与える影響
The role of dignity in nursing ethics: what it means; how it has evolved; and why it matters to nurse practitioners
Professor Ann Gallagher◉University of Surrey, UK & Editor, Nursing Ethics
IntroductionI would like to begin by thanking Professor Ota,
Professor Konishi and colleagues in the Japanese Nursing Ethics Association for the invitation speak at this conference. It is always a great pleasure to visit Japan and to learn from its people and very fine cultural, literary and philosophical traditions.
A conference on the theme of dignity in care is very important and gives us the opportunity to discuss to-gether how we might understand the dignity of pa-tients, of practitioners and of the nursing profession. We also need to understand how we promote dignity in our work with patients, families and colleagues and how we can have healthcare practices and orga-nizations that promote rather than diminish dignity.
There has been a great deal of attention to digni-ty in health care in recent years. Sadly, this seems mostly due to reports of indignity in care contexts where patients have been neglected, disrespected and sometimes, abused.
The first article on dignity appeared in the jour-nal Nursing Ethics in 1998. Since then we have had over 20 articles in the journal Nursing Ethics with a special online issue edited by Dagfin Nåden and colleagues in 2013. There are also many more arti-cles in other journals and books on this topic, in-cluding some that have argued that dignity is a ‘useless’ or ‘stupid’ concept.
I hope to persuade you that dignity is neither useless nor stupid. I will argue that dignity is, on the contrary, a core value in nursing ethics. And it
3 . 尊厳の学問と研究との関わりまず最初に、私の研究が尊厳とどのように関わってきたかについてお話ししたいと思います。始まりは1999年、その年に、哲学者であるDavid Seedhouse教授の研究助手の職を得ました。Seedhouse教授は、看護師に主要な看護の概念を教える効果について研究したいと考えていました。私たちは、尊厳に的を絞ることで合意し、看護師に尊厳を教えることにより看護の質は高まるだろうかという疑問に答えるため、疑似実験、準実験、を考えました。この関わりから、私は尊厳という概念に大きな関心をもつようになり、2004年のNursing Ethics誌に、「尊厳と尊厳の尊重」という概念論文を発表しました。数年後、私はPaul Wainwright教授と共同し、尊厳に関する論文をいくつか出しました。たとえば、2008年のNordenfeltの尊厳の類型論の批評や、尊厳の文献レビューです。また、私たち二人に、もう一人の同僚であるLesley Baillie教授も加わり、英国看護協会委託の尊厳に関する調査も行いました。これは、私共の知るかぎり、看護師の尊厳調査としては最大のもので、2000以上の回答を得ました。私たちは尊厳の定義を定め、尊厳は、個人、組織、およびより広範な社会との関連のなかで考慮する必要があると主張しました。また、英国看護協会の尊厳プロジェクトの評価を行い、教材開発にも貢献しました。現在私は、太田教授のチームと協力し、患者尊厳測定尺度国際版の検証を行っています。また、サリー大学とオックスフォード大学のチームとともに「ENACT」(Empowering Nurses to provide Ethical leAdership in Care homes supported by a dignity
is more than this. Dignity is the first value, the val-ue that other values spring from, the value we need to articulate the worth of fellow human beings, of ourselves and of our profession.
To develop this position, I will draw on the philo-sophical and empirical research literature relating to dignity and will engage with some examples of liter-ature and film from Japanese authors and directors.
In this talk I will then•Engage with dignity scholarship & research•Introduce a critique of dignity̶from Macklin and
Pinker•Discuss the background to increased attention to
dignity in care•Outline a historical perspective on dignity•Introduce perspectives from moral philosophy &
from empirical research•Cite examples from literature and film, for exam-
ple, the Warrior, the Housekeeper, the Professor, the Butler and the Undertaker
•Draw conclusions and recommendations for nurse practitioners
Engagement with dignity scholarship & researchI would like to begin by giving an account of my
research relationship with dignity. It began in 1999, when I accepted a position as research assis-tant with philosopher, David Seedhouse. Professor Seedhouse wanted to research the effectiveness of teaching nurses about a key nursing concept. We agreed to focus on dignity and designed a quasi- experiment to respond to the question: Does teach-ing nurses about dignity improve care? As a result of this, I became very interested in the concept of dignity and published a conceptual paper̶Dignity and Respect for Dignity̶in Nursing Ethics in 2004.
Some years later I worked with Professor Paul Wainwright on publications relating to dignity, for example, a critique of Nordenfelt’s typology of dignity and a literature review of dignity(2008).Professor Wainwright and I also worked with another col-league̶Professor Lesley Baillie̶on a dignity sur-vey commissioned by the Royal College of Nursing(RCN).This is the largest dignity survey of nurses we know of with over 2000 responses. We construct-ed a definition of dignity and argued that dignity needed to be considered in relation to individuals, or-ganizations and the wider society. We also conducted
Macklinの論文が、イギリス医学会会報で発表されました。論文のタイトルは「尊厳は役に立たない概念である。これは、人または人の自主性への敬意以外の何物でもない」というものでした。Macklin教授は、尊厳は、生命倫理学や人権に関する文書で、ほとんどまたは全く定義されずに使われており、「救いようのないほどあいまいなもの」であり、「医療倫理におけるこの概念は、いかなる実体も失うことなく排除できる」と主張しています(BMJ 2003, Volume 327, p. 1420)。
二つめの批評は、心理学者であり作家でもあるStephen Pinkerによるもので、2008年のThe New
an evaluation of the RCN dignity project and contrib-uted to the development of educational materials.
I am currently collaborating with Professor Ota & colleagues on the validation of an international dignity measurement tool. I am also working with colleagues at the Universities of Surrey and Oxford on the ENACT project, that is, Empowering Nurses to provide Ethical leAdership in Care homes sup-ported by a dignity Toolkit(ENACT).This is an action research project designed to develop a digni-ty toolkit that can empower nurses to provide lead-ership on dignity in care homes.
Finally, as Editor of Nursing Ethics̶I receive reg-ular ‘dignity’ submissions. Many of these are quali-tative studies. I have, therefore, been much engaged in thinking about and researching dignity in care.
This slide reminds me of the subjective dimen-sions of dignity. It was the response of an older pa-tient in a hospital in London when I asked her ‘what does dignity mean to you?’. The patient said ‘It means having a saucer with my cup’.
Despite the increased research attention to digni-ty, it needs to be said that not all academics are supportive of dignity. Two are noteworthy: Ruth Macklin and Stephen Pinker.
Critique of DignityIn 2003 an article by American bioethicist, Ruth
Macklin, was published in the British Medical Journal. The title of the article was ‘Dignity is a useless concept: It means no more than respect for persons or their autonomy’. Professor Macklin ar-gued that dignity is used in bioethics and human rights documents with little or no definition and it is ‘hopelessly vague’ and the ‘concept in medical ethics can be eliminated without any loss of con-tent’(BMJ 2003, Volume 327, p.1420).
A second critique is from psychologist and au-thor, Stephen Pinker, and was published in The New Republic in 2008. He argued that dignity ‘is a squishy, subjective notion, hardly up to the heavy-weight moral demands assigned to it’. He was criti-cal of a 2001 report called Human Dignity and Bio-ethics put together by the President’s Council on Bioethics under the leadership of US President George Bush. Pinker argues, roughly, that the con-cept of dignity has been manipulated for political purposes. He argues too that the President’s Coun-cil dignity report is confusing saying:
The President’s Council dignity report is confus-ing: Almost every essayist concedes that the concept remains slippery and ambiguous. In fact, it spawns outright contradictions at every turn. We read that slavery and degradation are morally wrong because they take someone’s dignity away. But we also read that nothing you can do to a person, including en-slaving or degrading him, can take his dignity away. We read that dignity reflects excellence, striving and conscience, do that only some people achieve it by dint of effort and character. We also read that every-one, no matter how lazy, evil or mentally impaired, has dignity in full measure’ (Pinker S, 2008).
We can see, then, how important it is to have a good understanding of dignity so that we can re-spond to such critique and act ethically in our healthcare practice. As nurse practitioners you need to understand how dignity evolved and how you can promote the dignity of patients, family, colleagues and their profession. Before I move on to this, I will say a few words about the rationale for the focus on dignity in our health services at this time.
Dignity̶why now?In the United Kingdom we have had many care
scandals where there have been care failings in hospitals and care homes. The highest profile scan-dal in recent years was at a hospital in England. A BBC report in 2013 said that:‘NHS [National Health Service] staff should face prosecution if they are not open and honest, according to a public inquiry into failings at Staf-ford Hospital. Years of abuse and neglect at the hospital led to the unnecessary deaths of hun-dreds of patients. But inquiry chairman, Robert Francis QC, said the failings went right to the
top of the health service. He made 290 recom-mendations, saying “fundamental change” was needed to prevent the public losing confidence’.
A strong theme of the Francis report and previ-ous reports on care deficits was a focus on a ‘cost cutting and target-chasing culture’ in the hospital. Hospital management prioritized meeting financial targets while fundamental care was neglected. The report tells of ‘patients left crying out for help be-cause they did not get pain relief and food and drinks being left out of reach’(Triggle, 2013).
We can summarize this problem as ‘meeting the target and missing the point’.‘Indignity in care’ was regularly referred to as a con-sequence of this neglect for patients and families re-sulting in great distress and, in some instances, death.
There have been many UK responses to this and other care scandals. A dignity commission was set up, new codes were created, dignity champions were identified to lead the dignity agenda in hospi-tal & charters were published. One Charter from the Royal College of Nursing states that:
‘Dignity has been a core theme for the RCN for some time. Members and staff should treat each other with dignity and respect, care and consider-ation, as well as valuing the rich diversity that everyone brings to the RCN.
This charter sets out the rights and responsibili-ties of all RCN members in relation to their interac-
図2
100 日本看護倫理学会誌 VOL.7 NO.1 2015
この憲章は、すべての英国看護協会の会員が、会員同士で交わるときおよび英国看護協会のスタッフと交わるときの権利と責任を定めたものです(Royal college of Nursing, 2010)。もう一つの最近の尊厳に関する取り組みの例は、英国年金生活者会議(2012)の「尊厳規定」で、次のように規定しています。「この尊厳規定の目的は、しだいに自分の世話や自分の用事を適切に行うことができなくなるものの健康、安全および幸福を確保するという背景において、高齢者の権利を擁護し、個人の尊厳を維持することである」と述べています。
tion with each other and with RCN staff(Royal College of Nursing, 2010).
Another example of a recent dignity initiative is the National Pensioners’ Convention(2012)Dignity Code. This states that ‘The purpose of this Dignity Code is to uphold the rights and maintain the per-sonal dignity of older people, within the context of ensuring the health, safety and well-being of those who are increasingly less able to care for them-selves or to properly conduct their affairs’.
This Code recognizes that certain practices and ac-tions are unacceptable to older people and calls for:•Respect for individuals to make up their own
minds, and for their personal wishes as expressed in ‘living wills’, for implementation when they can no longer express themselves clearly
•Respect for an individual’s habits, values, particu-lar cultural background and any needs, linguistic or otherwise
•The use of formal spoken terms of address, unless invited to do otherwise
• Comfort, consideration, inclusion, participation, stim-ulation and a sense of purpose in all aspects of care
•Care to be adapted to the needs of the individual•Support for the individual to maintain their hy-
giene and personal appearance•Respect for people’s homes, living space and privacy•Concerns to be dealt with thoroughly and the
right to complain without fear of retribution•The provision of advocacy services where appro-
priate(See NPC-www.npcuk.org)
I am sure that readers will be familiar with one of the most important international declarations̶the Universal Declaration of Human Rights̶that puts dignity at the centre. Article 1 states that:‘All human beings are born free and equal in dig-nity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood’ (United Nations 1948).Some human rights documents refer to dignity in
a negative sense, for example, the Article 3 of the UK Human Rights Act 1998 refers to the:‘Prohibition of torture: no one shall be subject-ed to torture or to inhuman or degrading treat-ment or punishment’(UK Government 1998).There are then charters, codes̶including profes-
sional codes from nursing organizations̶and decla-rations that highlight the importance of dignity. However, they generally provide little guidance as to
101日本看護倫理学会誌 VOL.7 NO.1 2015
論を含む哲学の文献をみる必要があります。
6 . 道徳哲学からの視点(1)(図3)オランダ人学者のRieke Van der Graafおよび
Johannes Van Delden(2008)は、「尊厳の意味の歴史」をたどると、現在の尊厳を明らかにするのに役立つと主張しています。そして尊厳について異なる意味をもつ5つの時代を特定しています。(1)最初は、古代ローマです。尊厳またはdignitasは、ローマ共和国の貴族や高い役職者、すなわち執政官や元老院議員に関連づけられています。Dignitasには際立った特色があり、たとえば、軍事や政治における傑出した業績に関連します。道徳的品位を示すこともその重要な部分を占めます。キケロは「人は、どのような行動をとるときも、自分の洗練された外見や尊厳に影響を与えるようなすべてのものを慎重に調節するべきである」と述べています。(p.154)つまり、尊厳とは「目にみえる資質」であり、「程度」に差があるものとしています。そして、個人に尊厳を与える他のものとの関係が重要であるので、これは関係的尊厳であると主張されます。(2)Van der GraafとVan Deldenが特定する2番目が、キリスト紀元です。この時代では、人は、神の姿(imago Dei)で造られ、神により与えられた尊厳を有すると信じられました。この種の尊厳は失われる可能性があると同時に無条件のものでもあります。(3)次に、ルネッサンス期のイタリアの人文主義者の著作では、尊厳を神の姿や魂の不滅性と関連づけるばかりでなく、自分がなりたいと思うものを選択する自由意思や能力という視点からみた人の非宗教的資質と関連づけています。これは、「自覚的な尊厳」として説明されるものであり、人はこれを最大限に利用する義務があるとされました。
what dignity means. To understand different per-spectives on dignity we need to look to the philosophi-cal literature, including a historical review of dignity.
Perspectives from moral philosophy(1)Dutch academics Rieke Van der Graaf and Jo-
hannes Van Delden(2008)argued that ‘historical meanings of dignity’ can help us clarify dignity in the present time. They identify five different histor-ical periods that offer different meanings of dignity:(1) The first is from Roman Antiquity where dig-
nity or dignitas was related to ‘the nobility and men in high offices(consuls and senators)in the Republic. Dignitas has particular features, for example, it relates to outstanding performance in the military or politics. Demonstrating moral integrity is an important part of this. Cicero writes that ‘men should be careful to mod-erate all things that may affect their refined appear-ance and dignity when undertaking any action.’ (p.154).This identifies dignity as a ‘visible quality’ and one that can ‘come in degrees’. It is argued that this is relational dignity as it focuses on relationships with others who bestow dignity on individuals.(2) The Christian era is the second identified
by Van der Graaf and Van Delden̶In this period, it was believed that persons are created in the im-age of God(imago Dei)possessing dignity, given to them by God. This kind of dignity can be lost and is, at the same time, described as ‘unconditional’.(3) Italian humanists, writing during the
Renaissance, related dignity not only to the image of God and the immortality of the soul but also to non-religious qualities of the person in terms of
Lennart Nordenfelt(2004)はノルウェーの哲学者ですが、尊厳の4つの型または種類について説明しています。最初はMenschenwürdeの尊厳です。Menschenwürdeとは、ドイツ語で、私たちが人間であるからという理由のみで私たちすべてが同じ程度にもっている尊厳の種類を意味するドイツ語です。二つめは、功績としての尊厳です。人は一定の役割または職務をもっていることを基に、または行動を通して得た功績があるという理由で権利をもちます。功績を基に権利をもつのであり、よって、特別な尊厳を有しているとして扱われます。三つめは、道徳的資質の尊厳です。この種類の尊厳
their free will and ability to choose what he be-comes This is described as ‘subjective dignity’ which people have a duty to make the most of.(4) The fourth historical period is described as
‘the Age of Reason’̶ The writing of philosopher, Immanuel Kant, was very important in this era. ‘Kantian dignity’ includes the view that ‘rational
beings have dignity insofar as they are capable of moral action, that is, of self-determination’. On this view autonomy Is the ground of human nature and of every rational nature’. Those who lack capacity are therefore excluded from dignity.(5) The Human rights era brings us to the
more modern view of dignity and refers us back to the Universal Declaration of Human Rights(UDHR).On this view, all human beings have dig-nity and are entitled to have their rights respected. This view was recognized as very important after the atrocities of World War II in particular and it is now very common to have dignity discussed in rela-tion to human rights.
These historical insights are interesting and you may be able to identify examples of these views of dignity in discussions and articles you have read. However, they may not help you to have a clear view of dignity in relation to care work. I turn next to two contemporary views and a definition of digni-ty that you may find helpful.
Perspectives from moral philosophy(2)Recent writing on dignity in relation to care sug-
gests different perspectives. The view of David Seed-house & Leila Shotten(now Toiviainen),for example, published in 1998 suggest that dignity relates to the:‘Interplay between circumstances and capabili-ties̶We lack dignity when we find ourselves in inappropriate circumstances, when we are in sit-uations where we feel foolish, incompetent, inad-equate or unusually vulnerable’.
On this view, we have dignity when our circum-stances and capabilities match and lack dignity when they do not.
Lennart Nordenfelt(2004)is a Norwegian philoso-pher who describes four types or varieties of dignity:
First, the dignity of Menschenwürde̶Menschen-würde is a German word meaning a kind of dignity ‘we all have to the same degree just because we are
all humans’.Second, dignity as merit̶People have rights on
the basis of holding certain roles or office or be-cause they have earned merit through their actions. They have rights on the basis of merit and are, therefore, treated as having a special dignity.
Third, the dignity of moral stature̶This kind of dignity is based on the moral stature that emerges from actions and omissions and from the kind of peo-ple they are. We might think of the late Nelson Man-dela as someone who had this dignity of moral stat-ure. There are degrees of this type of dignity and it is dependent on a person’s action so may come and go.
Finally, the dignity of personal identity̶This kind of dignity is related to one’s identity as a per-son and is related to self-respect. It is connected with concepts such as integrity, autonomy and in-clusion. This kind of dignity can be taken away from people when, for example, they are humiliat-ed, insulted or treated as objects.
These and other perspectives on dignity help us to think about dignity in relation to our own health-care and educational practices. But are they clear enough to guide our everyday work?
I suggest that a clearer definition that emerged from the research we undertook with the Royal Col-lege of Nursing(Baillie, Gallagher & Wainwright, 2008)is as follows:(RCN definition)
‘Dignity is concerned with how people feel, think and behave in relation to the worth or val-ue of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued indi-viduals. In care situations, dignity may be pro-moted or diminished by: the physical environ-ment; organizational culture; by the attitudes and behaviour of the [care] team and others and by the way care activities are carried out.
When dignity is present, people feel in control, valued, confident, comfortable and able to make decisions for themselves. When dignity is absent people feel devalued, lacking control and comfort. They may lack confidence and be unable to make decisions for themselves. They may feel humiliat-ed, embarrassed or ashamed.
Dignity applies equally to those who have ca-pacity and to those who lack it. Everyone has equal worth as human beings and must be treat-ed as if they are able to feel, think and behave in relation to their own worth and value. The [care] team should, therefore, treat all people in all set-
tings and of any health status with dignity, and dignified care should continue after death.’
The definition is published in the research re-port: Defending Dignity: Challenges and Oppor-tunities for Nursing(Baillie, Gallagher & Wain-wright, 2008).
I would ask. Is this a good fit for your practice as nurse practitioners, students, educators and re-searchers?
Important insights regarding dignity in care can also be gained from empirical research published in Nursing Ethics and elsewhere. I turn to this next(see, Naden et al., 2013).
There have now been a good number of empirical studies relating to dignity in care detailing the expe-riences of patients, family members and nurses. Here there are 3 examples from Scandinavia and the UK. The study by Lohne and colleagues(2010)helps us to understand the experience of patients with multi-ple sclerosis and the ‘lonely battle’ they are fighting.
The Royal College of Nursing study(Baillie, Gallagher & Wainwright, 2008)mentioned earlier draws our attention to different levels of dignity̶at the micro-level relating to individuals, at the me-so-level relating to organizations and at the mac-ro-level relating to societal and political contexts. This work also identified three areas that need to be considered and were incorporated into the RCN defi-nition of dignity: people(attitudes and behaviour); place(organizational culture and the physical envi-ronment); and processes(considering interventions that make people most vulnerable to indignity).
The third study reports the perspectives of care providers, particularly in relation to their work with people experiencing dementia. Some of these everyday ethical challenges relate to the refusal of care and treatment by older people. One worker, for example, said:‘When a patient won’t get washed. It’s difficult and hurtful to do what the patient doesn’t want. We’ve been trained to respect the patient’s histo-ry̶but some things have to be done . . . I have a patient who will never wash and look after her-self. Some days I dread going to work’.It is clear that everyday care can be challenging
particularly when patients do not want what profes-sionals think is good for them. We need to consider carefully how we best respect the dignity of the per-
son and demonstrate the dignity of our profession as nurse practitioners, educators and researchers.
We can also learn a great deal about the dignity of professional practice from the arts and literature.
Perspectives from Japanese literature and film̶the Warrior, the Housekeeper, the Pro-fessor, the Butler and the Undertaker
There are many examples in Japanese literature and film relating to dignity. Historical texts such as Bushido: The Way of the Samurai, for example, makes explicit reference to dignity. In Book 2, for example, there is a section on ‘Dignity’. It states:‘The way you look is literally the expression of your own dignity. Your dignity can find expression in many ways: in your efforts; in your graceful, mild manners, in the calm and silence of your bear-ing; in your grave conduct; and in the piercing stare effected with clenched teeth. These are all ex-pressions of your inner dignity. After all, the funda-mental lies in your being seriously aware with total concentration of mind’ (Yamamoto T, 2002, p.51).A contemporary Japanese novel which deals very
sensitively with the topic of dignity in the relation-ship between a housekeeper and a brilliant Professor of mathematics is by Yoko Ogawa(2010). The Pro-fessor has a serious short-term memory deficit as a result of a head injury and he can only remember for 80 minutes. In one section of the novel, the Professor had found a visit to the barbershop very stressful and had regained his composure in the park as he traced the numbers he was so comfortable with on the ground. The Housekeeper described the situation:‘the Professor picked up a branch and began to scratch something in the dirt. There were num-bers, and letters, and some mysterious symbols, all arranged in neat lines. I couldn’t understand a word he has said, but there seemed to be a great clarity in his reasoning, as if he were pushing through to a profound truth. The nervous old man I’d watched in the barbershop had disappeared, and his manner was now dignified’ (p.44).Another well-known novel by a Japanese author
is The Remains of the Day by Kazuo Ishiguro. This novel is about a butler, Stevens, and much of the fo-cus of the novel is on professional dignity. Ishig-uro’s description of the ‘great’ butler could also ap-ply to the great nurse practitioner. He says:‘the most crucial criterion is that the applicant be possessed of a dignity in keeping with his posi-
tion . . .‘great’ butlers . . . it does seem to be that the factor which distinguishes them from those butlers who are merely competent is most closely captured by this word ‘dignity’ [. . .] ‘dignity’ has to do crucially with a butler’s ability not to aban-don the professional being he inhabits. Lesser butlers will abandon their professional being for the private one at the least provocation [. . .] The great butlers are great by virtue of their ability to inhabit their professional role and inhabit it to the utmost; they will not be shaken by external events, however surprising, alarming or vexing’.
The fourth example relates to a Japanese movie ‘Departures’ that some of you may have seen. It
tells the story of a young man, Daigo Kobayashi, who becomes a ‘Nokanshi’ or funeral professional(undertaker in the UK).Daigo’s journey from nov-ice to expert in this area of practice that requires great sensitivity and respect teaches us a good deal about the art and dignity of practice. It teaches us also how to respond to families who are grieving.
What we can learn from these accounts is the im-portance of sensitivity in professional relationships. We learn also about the importance of valuing the life and personhood of others and of reflection on the values we profess. The Housekeeper had great respect for the mathematical genius of the Profes-sor and also was able to reflect on her relationship with him so that it demonstrated respect for his dignity. The butler, Stevens, demonstrated profes-sional dignity in the service of his employer but his behaviour suggested that he may not have engaged in critical reflection on values that we would con-sider important for healthcare practice. Values, for example, such as loyalty, justice and courage. The practice of Daigo in ‘Departures’ illustrates beauti-fully the art of practice and the comfort that can come from the development of expertise.
Conclusions and recommendations for nurse practitioners
To summarize then, we can see that insights re-garding dignity can be gained from philosophical ethics. Different historical perspectives have been introduced identifying ancient, religious, Kantian and human rights perspectives on dignity. A defini-tion from the Royal College of Nursing was suggest-ed that emphasized worth and value in the way peo-ple feel, think and behave. We considered also some
findings from empirical research, particularly quali-tative studies and reflected on perspectives we find in literature and the movies that may throw light on the complexity of dignity in healthcare practice.
We know that dignity can be promoted by ethics education such as attending this conference and by strategies such as role modelling, ethical leadership and refining skills in negotiation. Crucially we all need to remember that, however respectful of dignity our practice is, there is always room for improvement. Hence, it is appropriate to think of an ethics of aspira-tion. An ethics that enables us to reflect critically on how we flourish as individuals and enable those we provide care to and work with also to flourish.
Finally, I want to argue that dignity is the spring from which other values flow. It is the first and most fundamental value expressing the worth and value of all people and the worth of our most im-portant profession that has the most potential to make the most profound difference to the lives of patients, families and communities. Dignity is not, however, the only value and needs to underpin val-ues such as justice, courage, kindness, integrity and wisdom.
Understanding dignity enables nurse practitioners to engage meaningfully with the value and worth of patients and families, with their professional identi-ty and with the nursing profession. Nurse practi-tioners need to consider dignity at all levels: in your relationships with individual patients, family mem-bers, students and colleagues(micro-level); in your relationship with healthcare organizations asking if their values are the right ones or those that ‘meet the targets and miss the point’ (meso-level); and in society more generally(macro-level).
Dignity matters to nurse practitioners because it reminds professionals of the purpose of care prac-tices. What people outside nursing also need to be reminded of is the dignity of the profession of nurs-ing. Too often, nurses devalue their work and say ‘I’m just a nurse’.
I would like to finish this presentation with the words of Susanne Gordon, an American journalist, which reminds us of the dignity of our profession and the outstanding difference that our profession makes to the lives of people in Japan and around the world. Gordon states:
I’m just a nurse.” I just make the difference be-tween life and death.
I’m just a nurse.” I just have the educated eyes that prevent medical errors, injuries and other catastrophes.
I’m just a nurse.” I just make the difference be-tween healing, coping and despair.
I’m just an oncology Np.” I just make the differ-ence between a patient experiencing excruciating pain or fighting their disease relatively pain free.
I’m just a nurse.” I’m just a nurse researcher who helps nurses and doctors give better, safer and more effective care.
I’m just a nurse.” I’m a professor of nursing who educates future generations of nurses.
I’m just a nurse.” I just work in a major teaching hospital managing and monitoring patients who are involved in cutting edge experimental medical research.
I’m just a nurse.” I just educate patients and families about how to maintain their health.
I’m just a nurse.” I’m just a geriatric nurse prac-titioner. I make the difference between staying in one’s own home and going to a nursing home.
I’m just a palliative care nurse.” I just make the
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difference between dying in agony and dying in comfort and with dignity’