Kant in Present Oncology Nursing Realities.

Nursing as a discipline has consistently borrowed ideas from science and philosophy to establish reality and truth. To improve the care of patients with cancer, oncology nursing science must focus on areas of study that address relevant cancer care issues and have a major impact on people with cancer. This article attempted to explore the philosophical views of Immanuel Kant in relation to the present oncology nursing realities. The connections of the views of this philosopher as applied to modern cancer care were explored. The researchers attempted to identify certain components in these philosophies that best suit the present nursing realities in cancer care, especially regarding ethical and moral practices. From the analysis, Kant identified strategic issues that are directed toward strengthening the oncology nurse's commitments to the patients with cancer.

In search for the truth inherent in nursing, the discipline has consistently borrowed ideas from science and philosophy. This approach has significantly influenced the development of nursing knowledge and has yielded an understanding of nursing from the scientific, disciplinary, and professional perspectives.[1]

Nursing is also considered an art, wherein the basis of nursing knowledge is caring.[2] This is consistent with the perspectives of major nurse theorist such as Leininger and Watson. In fact, McCurry et al. opined that philosophical perspectives, disciplinary goals, theory, and practice should be linked together to establish the art and science of nursing.[3] With the rapid advancement in cancer treatment and the continuously changing health-care environment, nurses constantly are challenged to provide effective patient care. To improve cancer care, oncology nursing science must focus on areas of study that address relevant cancer care issues and have a major impact on people with cancer.

This article is concerned with the exploration of the philosophical views of Immanuel Kant to explain the modern ethical realities in oncology nursing.

Historical Context of Immanuel Kant

Immanuel Kant was a German philosopher who happens to be a central figure in modern philosophy. He was born in the Town of Konigsberg, East Prussia in 1724. He was raised in a large but relatively poor family. Kant, in 1740, entered the University of Konigsberg where he developed a strong interest for philosophy, mathematics, and natural science. Because of the death of his father, he was made to work as a private tutor for 7 years to raise funds to continue his education, during which he published several papers. Kant was relentless in publishing his papers until he was awarded a professorship in 1770.[4]

In addition to his famous works widely published in literature, Kant influenced the deontological movement. His philosophy entails that morally correct things must always be guided by moral duties, rights, and responsibilities,[5] and that the moral rightness or wrongness of an action cannot be judged only on the basis of the outcome. This philosophical doctrine has ignited a lot of ongoing arguments within the health-care ethics.[6]

Application of Kant's Categorical Imperatives to Oncology Nursing

Kant's theory is based on three categorical imperatives. A categorical imperative binds us regardless of our desires.[5] For example, it is established that everyone has a duty not to lie, regardless of the circumstances and even if it is in our interest to do so. The first categorical imperative prescribes that oncology nurses must act in such a way that they would will as a universal law. This implies that in the course of our care for patients with cancer, our actions should be such that we would want others to follow. When our actions are based on this principle, it is then considered ethical. As oncology nurses, the rationales for our nursing interventions must be universal and should be applied to any rational being.[7]

The second categorical imperative involves respect for persons.[8] Oncology nurses are asked to act in such a way that they treat humanity, whether in their own person or in the person of others, always at the same time as an end and never merely as a means to an end.[5] Oncology nurses should not use their patients merely as a means because it would be inconsistent to treat another human being any differently that one would want to be treated. Kant considers every individual as a rational being.[5] For example, oncology nurses who involve patients in risky medical experiments without their knowledge deprive them of their ability to make a rational choice about participation; therefore, they are simply used as means to some ends. The fact that the outcome of the study might be beneficial to a larger number of people with cancer is not a justification.

The third categorical imperative sees the oncology nurse as a legislator of care. Therefore, the nurse is required to conform her actions to the actions expected of a legislator of laws. This implies that the moral obligation of the oncology nurse is to act on a generally acceptable principles and nothing less.[5] Consequently, the nurse has it as a responsibility, as a lawyer/advocate of patients, to ensure their rights to self-determination, help them to clarify their desires and values in order for them to make their informed decision.[9]

For an oncology nurse to comply with the categorical imperatives, she must ensure that her emotions are put under control. It involves reflecting and thinking of how our actions, inactions, and decisions affect our patients, relatives, and co-workers in the field.

Operating with Kant's philosophy, it becomes a difficult task to care for patients with cancer involving the need to communicate diagnosis, prognosis, risk, and benefits of treatment.[10]

Ethical Considerations in Oncology Nursing from the Lens of Kant

Cancer care raises complex and complicated ethical issues for patients, families, and the oncology nurses. Sometimes, decisions entail going beyond the patient's physical condition enabling the caregivers to decide on what they should do and why – not necessarily what they can do. Although ethical principles guide oncology nursing practice, nurses are faced with the challenge to fulfill their professional core duty. They encounter clinical situations that have ethical conflicts and often have difficulty articulating them.[11]

The main goal of Kant's ethical theory is to reveal the ultimate moral principle which is based on pure reason.[12] Kant's ethical theory has several supporting principles, but he established that the only principle that is good at all times is the ethical principle of good will.[5] According to this principles, oncology nurses take care of the needs of their patients because it is their responsibilities and not necessary because of any other personal or corporate motive.

It has been reported that oncology nurses may recognize what is appropriate and ethical behavior to be followed, but due to external pressures, they become unable to continue with the right action plan.[13] To recognize the dimensions of ethical problems involved in oncology nursing becomes a determining factor for tracing strategies to cope with these problems.

For example, sometimes the cancer patients are led by the physician to a treatment that the nurse knows is nonbeneficial, the patient is signing a consent form for surgery that the oncology nurse knows he does not understand the consequences, the nurse hears the physician minimize the possible side effects of stem cell transplant, a patient tells you how she is getting a first-class edge treatment for her cancer when the nurse is fully aware she is not, a family tells the oncology nurse not to mention chemotherapy with the patient because the patient is yet to be informed about his cancer. These are selected ethical challenges that are inherent in oncology nursing which forms part of the daily wear and tear of dealing with cancer patients.

Duty to Care

In the oncology settings, nurses are exposed to conditions that ordinarily they would want to distance themselves from. Such conditions include caring for the dying patients, exposure to the effects of chemotherapy and radiotherapy. An oncology nurse is obliged to care for her patients irrespective of the situation. The concept of duty-to-care may not really surface when the nurse is caring under routine or everyday circumstance. The controversy starts when caring is associated with some uncertainties. Nurses have stringent obligations of beneficence toward their patients. Therefore, they have special obligations to care in spite of the inherent uncertainties involved with caring for patients with cancer. By becoming an oncology nurse, the nurse agrees not only to abide by new rules but also accept the stress and consequences that would be unacceptable to others. According to Kant, if oncology nurses perform their duties only because of peer pressure or because the public expects them to do so, then their actions are morally wrong. Regardless of the situations at different places where oncology nurses practice, nurses should not practice only for the sake of receiving their daily wages. This compromises the caring component of nursing. To act in a morally worthy manner, oncology nurses must discharge their duties with an obligation to fulfill their promise both to the profession and to their patients.[14] Kant would consider an oncology nurse's duty to care binding without any personal consideration.

Patient's Autonomy

This principle requires nurses to recognize that others have the right to act autonomously and that cancer patients should never be used merely for the benefit of society but are always treated as rational people with their own goals. In this context, the autonomy of patients must be valued.[5] It is therefore crucial for the health professionals involved in cancer care to deliberate and also involve the patients and family to determine their decision-making capacity.[15] Oncology nurses should note that patients appreciate frank discussions of prognosis and goals of care.[16] Realistic discussions can be challenging; therefore, there is need to evaluate and respect the patients' preferences regarding the details of these discussions. In the situation whereby a patient cannot participate, the family must be reminded to consider what the patient would want in this circumstance, not what the family or nurse wants. Secker describes an autonomous person as a free, independent, and self-governing individual who decides and acts based on exclusive rational reasons and not by emotion or inclination.[17] The actions of the oncology nurse can either enhance or suppress the autonomy of the cancer patient. To enhance the autonomy of the patient, the oncology nurse should engage in actions that facilitate rational deliberation such as providing relevant information and promoting reflection and discussion. The nurse is also expected to help the patient overcome emotional and psychological hindrances that may limit their autonomy.

Informed Consent

The actions of the oncology nurse should be based on communication between the parties involved to discuss her interest and intentions for all to understand. Any form of coercion or manipulation must be avoided. Every individual is a rational being and must be fully involved in making a decision about his or her care. Kant, therefore, believed that all humans should have right to common dignity and respect.[5] For example, any oncology nurse who wishes to perform a procedure on cancer patients without their knowledge must be happy for all other nurses to perform procedures on her (the oncology nurse) without her consent. Kant's prescription on autonomy entails that a patient must be able to make informed decision about treatment, making it unethical and immoral to perform any activity or procedure without the knowledge of the patient.

The act of communicating patients' diagnosis, treatment, and risks to obtain informed consent is the legal responsibility of the physician. However, the nurse has it as a responsibility to guide and clarify doubts about the diagnosis and treatment to provide sufficient education to patients and reduce their anxiety.[18]

Disparities in Nursing Care

According to Kant's fundamental principles, it is morally wrong for oncology nurses to foster healthcare disparities.[19] As oncology nurses, we have the moral duty to address all disparities that exist in the oncology settings. Care disparities in cancer care violate the basic respect for persons.[5] It has been established that lack of access to care, lack of education and limited resources are major contributing factors to disparities in cancer care, Kant expects that everybody must be treated as a person regardless of their socioeconomic status or level of education. A study conducted to identify sources of ethical problems encountered by oncology nurses showed that inadequate working conditions such as lack of material resources and workforce are the factors contributing to ethical challenges in cancer care.[20] Caring for cancer patients based on preferential prejudices or nurses choice is morally wrong.

Good Will Principle

Good will according to Kant is the efforts of rational beings to do what he ought to do, rather than to act from inclination or self-interest.[5] Kant promoted good will extensively to the extent that he emphasized that all our actions are morally right if they are based on good will, regardless of the outcome. Based on this principle, an oncology nurse is expected to have her rationales strongly based on good will. The good will is still good even if it fails to achieve any goal and have moral worth than the good goals achieved by immoral actions. The principle of good will is all encompassing as in cuts across all areas of endeavor of the oncology nurse.

Empathy as the Building Block of Dignity

Empathy is a very important communication skill that has a strong potential to improve psychological outcomes for patients with cancer,[21] as such there is a need for cancer nurses to be empathic. This quality is the root of dignity for patients, and thus, health-care providers need to consciously adjust their communication styles to demonstrate that empathy. The oncology nurse is expected to place honesty and moral living over doctrinal beliefs, feelings over rationality.[19] In the oncology settings, nurses and other health-care professionals should not discuss or have conversations about a patient's care around him without involving him in the conversation.

Truth-Telling

Truth-telling is a key issue in the nurse–patient relationship in the oncology setting. Oncology nurses always encounter the challenge of truth-telling to patients with cancer. Nurses make decisions on a regular basis regarding what information to tell cancer patients. Huang et al.[22] in their pilot study reported that most oncology nurses expressed that truth-telling was the physician's responsibility. The participants also expressed that truth-telling was difficult for them. Other nurses expressed that family members required that the truth of cancer diagnosis and prognosis be concealed. Information issues have been reported to impact the psychological well-being of patients with cancer.[23]

Applying the categorical imperative of Kant, everyone has a duty not to lie, regardless of the circumstances and even if it is in our interest to do so.[5]

Conclusion

It has been established that cancer care is filled with various ethical considerations. Oncology nurses therefore, should consider their obligations to their patients as well as other stakeholders and make all necessary efforts to resolve potential conflicts that may interfere with the goal of their care. Ethical dilemmas call for the oncology nurse to carefully navigate the complexities of the care system to facilitate information delivery and promote communication among various team members, patients, and families.

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Conflicts of interest

There are no conflicts of interest.