Spirituality is a highly contested concept. Within the nursing literature, there are a huge range and diversity of definitions, some of which appear coherent whereas others seem quite disparate and unconnected. This vagueness within the nursing literature has led some to suggest that spirituality is so diverse as to be meaningless. Are the critics correct in asserting that the vagueness that surrounds spirituality invalidates it as a significant aspect of care? We think not. It is in fact the vagueness of (...) the concept that is its strength and value. In this paper, we offer a critique of the general apologetic that surrounds the use of the language of spirituality in nursing. With the critics, we agree that the term ‘spirituality’ is used in endlessly different and loose ways. Similarly, we agree that these varied definitions may not refer to constant essences or objects within people or in the world. However, we fundamentally disagree that this makes spirituality irrelevant or of little practical utility. Quite the opposite; properly understood, the vagueness and lack of clarity around the term spirituality is actually a strength that has powerful political, social, and clinical implications. We develop an understanding of spirituality as a way of naming absences and recognizing gaps in healthcare provision as well as a prophetic challenge to some of the ways in which we practise health care within a secular and sometimes secularizing context such as the National Health Service. (shrink)

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. (...) The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis. (shrink)

The paper offers an account of integrity as the capacity to deliberate and reflect usefully in the light of context, knowledge, experience, and information (that of self and others) on complex and conflicting factors bearing on action or potential action. Such an account of integrity seeks to encompass the moral complexity and conflict of the professional environment, and the need for compromises in professional practice. In addition, it accepts that humans are social beings who must respect and engage with the (...) moral position of others. This account is contrasted with a more traditional view of integrity as the rigid maintenance of consistency between professional practice and deeply held, but inflexible, moral principles. While this strong sense of moral conviction may be valuable as a source of moral motivation, e.g. in the case of whistle‐blowers, it is equally likely to lead to dogmatism and hubris. Professionals and their organizations are encouraged to foster the more complex and reflective form of integrity. (shrink)

In this paper, we reflect upon shame and humiliation as threats to personal and professional integrity and moral agency within contemporary health care. A personal narrative, written by a nurse about a particular shift in a British National Health Service Accident and Emergency Department, is provided as a case study. This is critically reflected and commented upon in dialogue with insights into the nature of shame and humiliation. It is suggested that Accident and Emergency is a locus that is latently (...) prone to dynamics of shame and humiliation, a potential exacerbated within a culture subject to externally‐determined time targets that are enforced by a top‐down system of surveillance and management. The result is that nurses may lose their sense of professional competence and responsibility, moral agency, and integrity, to their own personal detriment, as well as to the detriment of patients with whom they work. Insofar as examining a small part of a whole may suggest insights into the operation and ethos of a very large system, this very particular case study narrative/reflection has some important implications and lessons for the wider organization and provision of health care in Britain and beyond. (shrink)

In 2008 the United Kingdom Nursing and Midwifery Council (NMC) published the latest version of its code of conduct (The code: standards of conduct, performance and ethics for nurses and midwives). The new version marked a significant change of style in the Code compared with previous versions. There has been considerable controversy and the accrual of an extensive body of literature over the years in the UK and Europe criticizing nursing codes of ethics and questioning their ethical standing and their (...) usefulness. In this article we review the current NMC Code. We argue that the NMC has been misguided in labelling the Code as a code of ethics, and suggest that the new document falls short in many respects. (shrink)

This article provides a theoretical critique from a particular ‘ideal type’ ethical perspective of professional codes in general and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Code of professional conduct (reprinted on pp. 77-78) in particular. Having outlined a specific ‘ideal type’ of what ethically informed and aware practice may be, the article examines the extent to which professional codes may be likely to elicit and engender such practice. Because of their terminological inexactitudes and confusions, (...) their arbitrary values and principles, their lack of helpful ethical guidance, and their exclusion of ordinary moral experience, a number of contemporary professional codes in health and social care can be arraigned as ethically inadequate. The UKCC Code of professional conduct embodies many of these flaws, and others besides. Some of its weaknesses in this respect are anatomized before some tentative suggestions are offered for the reform of codes and the engendering of greater ethical awareness among professionals in the light of greater public ethical concerns and values. (shrink)

This special issue of Health Care Analysis originated in an conference, held in Birmingham in 2014, and organised by the group Think about Health. We introduce the issue by briefly reviewing the understandings of the concept of ‘flourishing’, and introducing the contributory papers, before offering some reflections on the remaining issues that reflection on flourishing poses for health care provision.

The purpose of this paper is to offer an account of ‘flourishing’ that is relevant to health care provision, both in terms of the flourishing of the individual patient and carer, and in terms of the flourishing of the caring institution. It is argued that, unlike related concepts such as ‘happiness’, ‘well-being’ or ‘quality of life’, ‘flourishing’ uniquely has the power to capture the importance of the vulnerability of human being. Drawing on the likes of Heidegger and Nussbaum, it is (...) argued that humans are at once beings who are autonomous and thereby capable of making sense of their lives, but also subject to the contingencies of their bodies and environments. To flourish requires that one engages, imaginatively and creatively, with those contingencies. The experience of illness, highlighting the vulnerability of the human being, thereby becomes an important experience, stimulating reflection in order to make sense of one’s life as a narrative. To flourish, it is argued, is to tell a story of one’s life, realistically engaging with vulnerability and suffering, and thus creating a framework through which one can meaningful and constructively go on with one’s life. (shrink)

The purpose of this paper is to offer an account of ‘flourishing’ that is relevant to health care provision, both in terms of the flourishing of the individual patient and carer, and in terms of the flourishing of the caring institution. It is argued that, unlike related concepts such as ‘happiness’, ‘well-being’ or ‘quality of life’, ‘flourishing’ uniquely has the power to capture the importance of the vulnerability of human being. Drawing on the likes of Heidegger and Nussbaum, it is (...) argued that humans are at once beings who are autonomous and thereby capable of making sense of their lives, but also subject to the contingencies of their bodies and environments. To flourish requires that one engages, imaginatively and creatively, with those contingencies. The experience of illness, highlighting the vulnerability of the human being, thereby becomes an important experience, stimulating reflection in order to make sense of one’s life as a narrative. To flourish, it is argued, is to tell a story of one’s life, realistically engaging with vulnerability and suffering, and thus creating a framework through which one can meaningful and constructively go on with one’s life. (shrink)

The paper offers an account of integrity as the capacity to deliberate and reflect usefully in the light of context, knowledge, experience, and information (that of self and others) on complex and conflicting factors bearing on action or potential action. Such an account of integrity seeks to encompass the moral complexity and conflict of the professional environment, and the need for compromises in professional practice. In addition, it accepts that humans are social beings who must respect and engage with the (...) moral position of others. This account is contrasted with a more traditional view of integrity as the rigid maintenance of consistency between professional practice and deeply held, but inflexible, moral principles. While this strong sense of moral conviction may be valuable as a source of moral motivation, e.g. in the case of whistle‐blowers, it is equally likely to lead to dogmatism and hubris. Professionals and their organizations are encouraged to foster the more complex and reflective form of integrity. (shrink)

Scant consideration has been given to the ethical implications of the policy of closing down psychiatric hospitals in favour of community care. The recent adherents of this policy in government have been enthusiastic in encouraging its implementation. This paper has three sections: a brief resumé of the history and principles of community care for the mentally ill; a discussion on the merits and de-merits of psychiatric care in the hospital and in the community; and an outline of some preliminary categories (...) for ethical analysis. (shrink)

The whole subject of values is surrounded by partiality, ignorance, confusion and ambiguity from the conceptual level down to the nitty gritty level of everyday practice. Some of these problems have been exposed in a preliminary way in this paper. A great deal more, and more detailed, work at conceptual and practical levels needs to be undertaken before we can really start to talk intelligibly and in a non-confusing way about value and values. One thing is clear. We will never (...) completely escape from the relativity and conceptual slipperiness that inheres in the very nature of valuing some things over others. Values are created in an ongoing dynamic process, not revealed. In the short-term, however, this knowledge will not convince politicians and other ideologues that values may not be in and of themselves a wholly desirable thing! (shrink)

ConclusionThe whole subject of values is surrounded by partiality, ignorance, confusion and ambiguity from the conceptual level down to the nitty gritty level of everyday practice. Some of these problems have been exposed in a preliminary way in this paper. A great deal more, and more detailed, work at conceptual and practical levels needs to be undertaken before we can really start to talk intelligibly and in a non-confusing way about value and values. One thing is clear. We will never (...) completely escape from the relativity and conceptual slipperiness that inheres in the very nature of valuing some things over others. Values are created in an ongoing dynamic process, not revealed. In the short-term, however, this knowledge will not convince politicians and other ideologues that values may not be in and of themselves a wholly desirable thing! (shrink)

ConclusionThe whole subject of values is surrounded by partiality, ignorance, confusion and ambiguity from the conceptual level down to the nitty gritty level of everyday practice. Some of these problems have been exposed in a preliminary way in this paper. A great deal more, and more detailed, work at conceptual and practical levels needs to be undertaken before we can really start to talk intelligibly and in a non-confusing way about value and values. One thing is clear. We will never (...) completely escape from the relativity and conceptual slipperiness that inheres in the very nature of valuing some things over others. Values are created in an ongoing dynamic process, not revealed. In the short-term, however, this knowledge will not convince politicians and other ideologues that values may not be in and of themselves a wholly desirable thing! (shrink)

In the UK, many fundamentally important policy decisions that are likely to affect the relationship between citizens and care services are now made at the sublegislative level and without adequate ethical consideration and scrutiny. This is well exemplified in the proposed guidance on the disclosure of information on children. A recent consultation paper by the UK government on the subject proposes an approach that seeks a simple technical solution to a complex problem, emphasising control and surveillance. This reflects pressure to (...) be seen to act. The document fails with regard to ethical reflection appropriate to the complexity of the issue, an appreciation of complex relationships of trust, and a proper sense of the richness and complexity of the public interest. Such policies would, if implemented, fundamentally change the relationships between citizens and their carers, and among carers and the law and the state. This and similar proposals require far more ethical scrutiny and consideration of the public interest in the widest sense. (shrink)

This article aims to challenge and expand notions of health, health care and health promotion, particularly in relation to smoking, via a consideration of the autobiographical literary work of the English playwright, Simon Gray. Gray died in 2008, having written a series of reflective autobiographical books, The Smoking Diaries. Gray was a lifelong smoker, perpetually trying to give up his habit. This article introduces Gray’s diaries and their reflections on life, death, health care and smoking. It then enquires what can (...) be learned about contemporary health care practices and assumptions from Gray’s work. Finally, it reflects on the limits of views of health and health promotion when considered in the light of a fully lived life. In the life under consideration, health care risks are very differently understood to those prevalent in the medical community. Literary approaches to thinking about smoking are thus seen to place health and health care in broader, richer, and less instrumental perspectives than those that are common amongst contemporary health professionals and institutions. (shrink)

This paper raises some issues about understanding religion, religions and spirituality in health care to enable a more critical mutual engagement and dialogue to take place between health care institutions and religious communities and believers. Understanding religions and religious people is a complex, interesting matter. Taking into account the whole reality of religion and spirituality is not just about meeting specific needs, nor of trying to ensure that religious people abandon their distinctive beliefs and insights when they engage with health (...) care institutions and policies. Members of religious groups and communities form an integral part of the structure and fabric of health care delivery, whether as users or in delivery capacities. Religion is both facilitator and resistor, friend and critic, for health care institutions, providers and workers. (shrink)