1. Schwarz, Judith K. MS, RN


Evaluating the ethical dimensions for the long-term.


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We health care professionals often wrap our practices in the mantle of concern for another's interests or the prevention of harm, when the real reason for many institutional policies is our own convenience. Such may be the case for the longstanding practice of prohibiting family members to be present during invasive procedures (IPs) or cardiopulmonary resuscitation (CPR). Now that this practice is being questioned, it's important to address both whom this change is primarily intended to benefit, and how family members are to be selected for participation. The study by Meyers et al. in this issue of AJN (see page 32) examines the perspectives of family members and providers, but remains curiously silent about patients' views. This commentary will highlight some ethical issues that should be considered in anticipation of this proposed policy change.



In 1995, the Emergency Nurses Association published guidelines to support a change in the way families were treated in emergency rooms. They recommended discontinuing the routine practice of banning family members from the bedside of patients during CPR or IPs. They should be commended for questioning a practice whose merits were assumed but never proven. Historically, it was assumed that family members would be too traumatized or disruptive if permitted to remain present during a loved one's CPR or IP, so they weren't given the choice. Readers will recognize this "we-know-what's-best-for-them" judgment as paternalism: interfering with the autonomous choice of a competent adult that is rarely morally justified.


Paternalism is pervasive in health care, in part because these interventions are intended to benefit others, most often patients. But good intentions alone don't morally justify an act.1 When considering a change in policy, it's important to ask: Whose needs are of primary concern? The identity of those most expected to benefit from this policy change seems to be family members and health care providers, or at least it was their views that were measured by Meyers et al. as outcomes. The benefits of family presence reported by the Meyers investigators include the family's awareness of the seriousness of the patient's condition, the family's realization that the providers did everything possible, and their relief from the anxiety of not knowing what was happening. Granted, there is nothing inherently wrong with institutional changes that benefit family members or significant others, and it could be argued that helping families in turn helps patients. When parents were finally permitted to room in with their hospitalized children, for example, the benefit to the child was clear. But we must be equally clear about who's at the center of our moral concern with the issue of family presence. Whose needs take priority during family presence and how will conflicts between the parties be resolved? Who is the "patient" in this setting? Is it just the patient, just the family, or the patient and family as a unit?



Furthermore, we need to consider how-or if-this policy will be explained to family members waiting in emergency rooms. Most rules and regulations in health care institutions are intended to benefit patients. That's the reason we give for restricting visits by virus-prone children or by too many people at once. Similarly, many acute care units limit visiting hours to provide patients the intensive technological attention they require and opportunities to rest. What these rules have in common is that they are clearly written, publicly stated, and applied similarly to all patients and visitors. While visitors may not like the rules, they are "fair" in that the same rules apply to everyone who is similarly situated. This is how the principle of justice, at its most basic, is applied; justice is understood as fairness.2


But will the policy of family presence be applied fairly? Will all families have the same opportunity to be present with loved ones, or will the screening process bias the outcome? The practice of "surreptitious screening" of candidates (screening family members while they're ostensibly being briefed by a nurse or chaplain about the patient's status) seems, at best, unfair. This provider assessment determines whether family members are suitable candidates to stay with the patient, but without their knowledge or consent.


The covert nature of this assessment raises concerns about bias. If the family member being assessed is from an ethnic, cultural, or socioeconomic group different from that of the assessor, there's a significant potential for biased value judgments. A number of studies have substantiated differences in coping style and values among members of different cultural groups.3 Such differences may lead to inaccurate judgments, and family members who might wish to remain with a loved one may not be given that choice if they are deemed unable to cooperate. Perhaps if they were told about the possibility of remaining with their loved one, apparently distraught family members could pull themselves together for the sake of the patient.



The Meyers study raises other questions. Family members interviewed after being present during CPR or IPs said that they had a "right" to be present; yet they also described the experience as something they felt "obligated" to do. Ethically, a "right" is a morally justified claim that others should respect, and by extension, it entails a responsibility on the part of others either not to interfere with that claim or to provide assistance.4 If family members felt they had a right to be with their loved one, presumably they also believed that the health care team should not prevent them from doing so, and perhaps should facilitate their being present. That family members also experienced an "obligation" to be present suggests that perhaps they felt it was so important to be with their loved one that they agreed to do so, despite possible preferences to the contrary. If hospital policies change, will families feel pressured to be present, even if they don't want to be? If, on the other hand, the health care team considers family presence a privilege, then it's more justifiable to selectively offer it to those who appear able to cooperate with the goals of the health care team. But regardless of whether it's a privilege or a right, institutions must publicly state the purpose of their rules and the circumstances under which exceptions will be made so that they will be applied with justice and fairness to all.


It's encouraging to see nurses question longstanding policies that may not serve patients and families well. But when developing new policies, we must also evaluate the significant ethical dimensions of the intervention for the long-term.




1. Paternalism. pg. 195-216. In: Gert B, et al., editors. Bioethics : a return to fundamentals. New York: Oxford University Press; 1997. p. xii, 320 [Context Link]


2. Rawls J. A theory of justice. Cambridge, MA: Belknap Press of Harvard University Press; 1971. [Context Link]


3. Perkins HS, et al. Cultural differences among health professionals: a case illustration. J Clin Ethics 1998;9(2):108-17. [Context Link]


4. Beauchamp TL, Childress JF. Principles of biomedical ethics. 4th ed. New York: Oxford University Press; 1994. [Context Link]