Nurse leaders’ role in medical assistance in dying: A relational ethics approach

Mutual respect

The concept of mutual respect is acknowledged within relational ethics through the observation of how an individual may treat a person in their care and through the ways nurses and patients engage and interact; that is, how they relate to each other. ¹² While respect is an essential element of nursing care, relational ethics takes mutual respect to involve acknowledgment of power differences, values, beliefs, knowledge, and experiences. ^11,16 With respect to MAID, this can play out in a struggle between the patient’s right to request an assisted death and a nurse’s right not to provide or participate in it, as protected by the Criminal Code amendment. ⁸ This law is in place to protect the vulnerable individual, but with such an emotionally charged subject, the nurse leader’s duty of care may be to support the mutually exclusive interests of a requesting patient and a conscientiously objecting nurse.

For the nurse leader, this support may take the form of being the point of contact for patients seeking information on assisted death, or between the patient and the MAID provider, to ensure direct care nurses are not asked to choose between their values and their job. Because nursing codes of ethics require a duty of care and non-abandonment, nurses cannot simply stop providing care when they disagree with a person’s choices. ^8,17 This means there is an obligation to facilitate, or at least not to impede the patient’s access to information about MAID. While a particular nurse may not feel that providing information is consistent with his or her personal values, and especially in contexts where there is no ethicist or central referral process, the nurse leader demonstrates respect for those values by being the intermediary, willing to provide the necessary information and make specific arrangements.

This is predicated on mutual respect between nurse and nurse leader, exemplified in the trust relationship that allows for an open discussion of the nurse’s personal values and beliefs and an understanding of the nurse as a person. The nurse leader needs to know and appreciate the nurse’s perspective on MAID in order to support their preferred level of involvement in the process. As they would attempt to arrange assignments or accommodate requests for time away for the nurse who objects, the nurse leader will facilitate a non-objecting nurse’s preferred level of involvement, recognizing that personal values and beliefs and the relationships nurses form with their patients may result in a desire to be part of the patient’s end-of-life experience. Similarly, for a nurse leader who is also a conscientious objector, respectful relationships with higher order leaders will allow for the establishment of a relationally ethical organization, with resources for supporting objecting perspectives at leadership levels.

Engagement

Engagement requires effort to understand the situation, perspective, and vulnerability of another person. ^11,16 Nurses engage with others to build trusting relationships and the capacity to meet fiduciary duties. ¹⁸ Nurse leaders provide nursing care, albeit in different ways than direct care nurses. Nurse leaders have fiduciary duties not only to patients and their families but also importantly to their direct reports, and engagement is a critical part of building and sustaining those relationships. A practice of “sitting down and leaning in” ⁶ is a way of connecting with people on an individual level, to explore and validate what is happening in the individual’s life. Sitting down with a nurse, literally, if possible, is an acknowledgment of the importance of their perspective. It can neutralize power differentials and sets the stage for a productive dialogue. Leaning in is an exploration of the context and circumstances that affect values, beliefs, and motivations. Sitting down and leaning in is a demonstration of respect and an acknowledgment of the humanity and the personhood of the individual. It will help a nurse leader guide the nurse’s exploration of their own values and how they might be expressed in the care of a patient requesting MAID, especially when the nurse is uncertain about MAID or their ability to effectively care for a patient who has requested it. Engagement will help a nurse leader when called upon to support nurses in this new moral environment, in order to understand and appreciate the values of others and to provide the care necessary to the well-being of that other, whether it is patient, family, or nurse.

In addition to supporting individual nurses in exploring their values and beliefs, engagement enables a nurse leader to understand, appreciate, and, as much as possible, accommodate the individual contexts and circumstances that influence the ability to provide effective nursing care in ways that protect nurses’ moral agency. Engagement can help the nurse leader support staff in balancing the duty to care with the right not to participate in MAID. Especially where the ability to reassign nurses to accommodate objection is limited, engagement helps the nurse leader truly understand the nurse’s values and the elements of the MAID process that present a barrier for an objecting nurse. The nurse leader thus fulfills the duties owed to patients, by ensuring complete, compassionate and appropriate care is provided, and to direct reports through accommodating objection as much as possible, protecting them from the need to decide between their conscience and their job.

However, when accommodation is not possible, or when the accommodation requested will interfere with the functioning of the unit or the care of one or more patients, the nurse leader must set expectations. The Canadian Nurses Association Code of Ethics outlines specific values and ethical responsibilities expected of registered nurses in Canada. ¹⁷ When difficult ethical decisions need to be made, nurse leaders are ultimately responsible for defining what care is and is not a direct part of the MAID process. Although participation in MAID is not required, provision of routine, non-MAID related care is (even for a patient who has requested MAID, up to the time of their death), and leaders will require strong engagement skills to navigate the moral tensions that arise in nurses, and nurse leaders, who feel MAID is morally indefensible.

Environment

Relational ethics requires an organization where ethical reflection happens. The organization’s environment is affected by the ethical moments that arise in the course of a day. ¹³ The ability to attend to these moments, explore their complexity, and then engage to achieve a resolution results from an environment of mutual respect. Nurse leaders are in a position to enable an environment where open discussion, reflection, and exploration are the norm. Ethical organizations establish open and respectful environments as an expectation.

Supporting the change in practice that is MAID will require exactly this kind of environment. Nurses can be expected to have a range of perspectives and views on MAID. It is an entirely new intervention in the scope of nursing practice, with the rights of both participation and non-participation protected by law. Nurse leaders will need to establish an open and trusting environment for the exploration of the emotions and opinions that will invariably arise with the topic of MAID. The ethical moments, when decisions are being made, or even hypothetically discussed, are the nurse leaders’ opportunity to establish a safe space. Just as nurses who object to MAID need to be accommodated, nurses who wish to participate may need support to facilitate the acquisition of skills and confidence in engaging with patients in this new way. The moment-to-moment decisions of everyday work in a caring profession are chances for the nurse leader to support ethical decision-making, acknowledging both the circumstances of the individual nurse, but also the wider context affecting a situation. For example, when a nurse feels a moral conflict in providing routine care to a patient who has requested MAID, it is critical for the nurse leader to bring awareness to the nurse’s reaction and help them learn about the impact and effect on the care environment that ensues. It is whether the nurse’s response to the situation can be disentangled from the situation and the environment that makes an important impact to the well-being of the individual. ¹⁹ This is a critical function of the nurse leader, when mediating incompatible value sets of patient and nurse.

While people navigate changes such as MAID in the healthcare system and society more broadly, relational ethics embraces the connections between individuals, the context of the environment, and how people are connected to those changes. ^11,16 Nurses can shape the nature of the healthcare environment within their daily practice, ²⁰ through careful attention to the ethical moments that play out in care decisions. Nurse leaders support this critical enterprise by establishing and maintaining an environment conducive to principled decision-making and providing respectful, non-judgmental support for nurses to engage in ethical reflection.

Embodiment

Embodiment is the acknowledgment that there are both physical and emotional elements to well-being. ¹¹ Illness is not felt just in terms of physical symptoms, but also in terms of its effect on ability, limitations, and even the self-identity of the person experiencing the illness. Ethical decisions are made within the context of relationships, and the impacts of decisions on the other parties in the relationship are important factors in determining what is right. Nursing care is responding to patients’ needs, as embodied in both the physical and the emotional/contextual impact of a health condition. In supporting nurses, both organizations and nurse leaders must recognize that this is relevant to caregivers as well. The healthcare provider also utilizes their own emotional experiences when making decisions in work situations. ¹⁶ An ethical organization recognizes and supports this.

Part of the role for nurse leaders now is to help nurses work through the process of reconciling the emotional elements of a post-MAID world with existing values and beliefs about the nature and scope of nursing practice, including the emotional work of responding to patients who have requested an assisted death and supporting family members who may not agree with a patient’s decision. For some, this will be simple; for others, the tensions between personal and professional values, between patient or family and nurse perspectives and life experiences will be challenging. For the nurse leader, recognition of the impact of this conflict on a nurse will be more complete with an understanding of how the work is situated within the context of the nurse’s personal values and life circumstances. Nurse leaders can support personal and professional decision-making by encouraging reflection, an activity fundamental to practice in any health profession.

In the context of MAID, nurse leaders can guide reflection by facilitating opportunities for nurses to explore the impact of MAID on their practice, including the nurse’s comfort level with conversations about end of life, and moving toward the extent to which a nurse might be willing to be involved, directly or indirectly, in an assisted death (including not at all). This type of self-reflection explores the emotional and contextual impact of the nurse’s decisions about MAID, allowing them to better articulate their position and providing the nurse leader with a richer ability to support the nurse’s values within the boundaries of the care work that needs to be done, irrespective of a patient’s intention to pursue MAID. For some nurses who conscientiously object to MAID, involvement with a patient who intends to pursue MAID will be limited to routine care. For others, who feel that MAID is consistent with their personal values and beliefs, it may be a more intimate role, including participation in assessment or preparation for the death and support of the patient, family, or other staff before, during, and after the death. The nurse leader facilitates the entire spectrum of nursing involvement, keeping in mind, as much as possible, what is known about an individual nurse’s beliefs and values about MAID. Where a nurse’s role is to identify and meet a patient’s care needs, a leader’s role is to identify and meet the care needs of nurses. Acknowledging the emotional impact of the sea change that is MAID will better able nurse leaders to identify the best way for nurses’ personal values and integrity to be preserved, while ensuring patient care needs are not ignored.

Limitations

Although it can certainly be argued that there are differences between the moral, organizational, and social tasks that nurses and leaders perform, this article is limited to a discussion on how nurse leaders support nurses in navigating morally difficult work. It excludes the interesting but separate questions of whether and how nurse leaders should reconcile their own personal values in these kinds of morally challenging situations. It also excludes consideration of the nature of nurse leaders’ relationships with higher order leaders in their organizations, that is, with those who support the resolution of nurse leaders’ own ethical conflicts, such as a conscientious objection to MAID.