"A Bioethical Decision-Making Guide: A Synopsis of Symphonology"
By Dr. Barbara Brown
Ethical decisions in health care are those decisions that profoundly affect the lives of people. In ancient times Ovid (ed. 1983) wrote about abortion and Socrates (Plato, trans. 1995) willingly accepted execution rather than abandon his values to keep his just agreements. Both of these are good examples that remind us that bioethical dilemmas have been faced by all ages. As present day health care professionals we are faced with bioethical dilemmas in all facets of the health care arena, from administration to the bedside. In order to deal with these decisions, we need a decision-making process that allows us to address these dilemmas within a rational, justifiable ethical framework. The bioethical theory of Symphonology (Husted & Husted, 1995) gives us just such a framework.
Symphonology is based on the supposition that an agreement exists between all rational beings. This agreement is implicit in nature and simply put it is the agreement not to aggress. In other words, I will not act against you and you will not act against me. Without this implicit agreement we would not be willing to drive a car or leave the protective walls of our homes. We call this freedom from aggression a negative right. This agreement is the basis for the agreements that are formed between healthcare professionals and patients, administrators and employees, health care institutions and the community they serve. In each instance of the agreement, the professional assumes the greater burden of the agreement. For example, the healthcare professional agrees to do for the patient what the patient would do, if able. The patient agrees to be the patient, to fulfill his responsibilities in the treatment plan and not place any unreasonable demands on the healthcare professional. The administrator agrees to treat employees with equal fairness and the employees agree to perform their specified functions within the organization. These agreements are contingent upon the bioethical standards of fidelity, beneficence, objectivity, self-assertiveness, freedom and autonomy. Agreements, implicit or explicit, would not be made if we thought that the person with whom we were agreeing would not be faithful to the agreement (fidelity); who would enter into any agreement unless there was some "good" to be achieved (beneficence); agreements require consent and consent can be obtained only through the sharing of truthful information (objectivity); unless a person was able to control his own time and effort an agreement could not be made (self-assertiveness); an agreement is valid only if the parties were not coerced or forced in any way; they must be given the opportunity to choose freely (freedom); and lastly no one would make an agreement if it meant losing their individuality, their uniqueness (autonomy).
When we bring together this knowledge about agreements with the context of the situation, we have the Symphonological framework to guide ethical decision-making. Hospers (1972), a philosopher in the not so distant past, said, "in ethics everything is contextual." The context of the situation is the objective reality of the situation as it exists at the time and place in which the decision must be made and it includes the capabilities of those who are relevantly involved. Certainly this is one of the strong points of Symphonology. When decisions are made considering the context of the situation we are not utilizing a lone concept such as "duty" or "the greatest good for the greatest number." We are not utilizing rules, cultural standards, personal beliefs, or emotions to make a decision. Instead, we are using the situation as it exists and the bioethical standards to come to a justifiable, rational, ethical decision.
Symphonology helps to unravel ethical dilemmas by providing healthcare professionals with an uncomplicated framework for ethical decision-making.
In general, Ethics can be defined as a system of standards to motivate, determine and justify actions that are taken in pursuit of vital and fundamental goals. It is the study of the good life, the way to bring about happiness. It has to do with what is important, our purposes, and what makes a long-term difference in our lives. To be more specific, Symphonology is defined as a practiced-based ethic that is patient centered. It is an individualistic ethic that unites the reason why a decision is made with the action itself and the foreseeable consequences of that action. It is a professional ethic that guides a nurse's interaction with patients, one human being with another. It demands that the nurse act by reasoning; that we should reason "to" a decision starting with the objective reality of the situation rather than reason "from" a decision, which means that we are starting with our own subjectivity, unquestioned beliefs, or feelings. The concept of acting according to reason is what makes ethics possible.
"In ethics everything is contextual and the context of every action is unique and unduplicable with the result that even a small difference between two situations may yield a difference in our moral verdict" (Hospers, 1972, p.63). Symphonology considers the situation in which the ethical action takes place and the knowledge the nurse possesses to bring to that particular situation. There is an interweaving of the "context of the situation" and the "context of knowledge" that provides the framework in which the ethical decision is made.
Basic to the symphonological decision-making process is the concept of agreement. As a matter of fact, Symphonology means the study of the agreement. We can make agreements because as humans we are rational beings, reasoning organisms, that are unique, free, objective, self-assertive, benefit seeking, and faithful. As unique persons we are unlike anyone else in the world; we are self-determined, we can exercise our power to pursue long term purposes; dealing with objective reality, controlling our own time and effort, pursuing values in order to live, being faithful to life. The most fundamental of agreements between humans, is the agreement of nonaggression. This implicit agreement between people is the result of a shared state of awareness and is the basis on which any interaction takes place. The agreement between people not to aggress is the simplest and most basic ethical context between humans; it determines what the ethical interaction ought to be because no interaction is even possible without this agreement. In an agreement both parties agree to live up to the commitment to the other. The nurse-patient agreement evolves from this most basic of agreements.
The agreements we make as ethical professionals contain six implicit agreements that are described as the bioethical standards. The bioethical standards are lenses to analyze and understand ethical situations; they make it possible to resolve ethical dilemmas and to see and understand other people. The six bioethical standards are as follows: fidelity, beneficence, self-assertion, objectivity, freedom, and autonomy.
Fidelity is faithfulness/commitment to the agreement. It is the agreement to adhere to the terms of the agreement. It is persistence in seeking to gain benefit or to avoid harm. Would we enter into an agreement unless we thought that the parties involved were going to be faithful to the agreement?
Beneficence means to do good, at least do no harm. The purpose of any agreement is to attain benefit. Would we enter into an agreement that was not beneficial?
Self-assertion or privacy is a person's power to control his own time and effort. If we could not control our own time and effort then we would not be able to form and carry through agreements.
Objectivity is the reality of the situation. It is a person's capacity to be aware of things as they are and to be able to act on this awareness. In order to exercise our rationality, we need to know the reality of the situation. A rational decision is not possible without objective knowledge of the situation.
Freedom is self-determination. It is a person's capacity to take independent action based on his evaluation of his situation. Freedom is understanding what we can and cannot do. We do not have unrestricted freedom. It is limited by the freedom of others.
Autonomy is made up of the essential character structures of an individual person. It is uniqueness, those qualities that make someone the unique person that he is. Autonomy includes those qualities that we share with as humans and those qualities that make us different.
An effective ethical agent would always do the right thing at the right time for the right reason with the right person to the right extent in the right way. This means keeping the agreement, staying in the context of the situation, using knowledge appropriately, and applying the bioethical standards to guide decisions and actions.
(Click here for a diagram of Husted's Decision Making Guide to illustrate the interconnectedness and use of the above points.)
Hospers, J. (1972). Human Conduct: Problems of Ethics. New York, Harcourt Brace Jovanich.
Husted, G. & Husted, J. (1995). Ethical Decision Making in Nursing 2nd ed. St. Louis, Mosby.
Jowett, B (translator). (1995). Plato: The Death of Socrates (Euthyphro, Apology, Crito, Phaedo). New York, Fordham University Press.
Ovid, P. Green, ed. (1983). The Erotic Poems: The Amores, the Art of Love, Cures for Love, on Facial Treatment for Ladies. USA, Penguin.