Create a weekly Ethics Log in which you record your thoughts in.
Record, in your Ethics Log, your response to the following:
• Reflect on an international health issue that has appeared in the media recently. Could this issue have been prevented? Why or why not?
• Does U.S. health care policy answer the needs of the health issue better than international policies? Why or why not?
Global Consciousness in the Twenty-First Century
Written in collaboration with Barbara Kupchak
What we remember, we can change; what we forget we always are.
After completing this chapter, the reader should be able to:
1. Discuss the relationship between Earth health and human health.
2. Describe the role and ethical responsibility of nursing in aIDressing local, national,
and global environmental issues.
3. Discuss nursing role, responsibility, and ethical stance in responding to local,
national, and global issues such as disaster, displaced persons, war and violence,
epidemics, and toxic chemicals and other pollutants.
4. Discuss historical events and patterns of health care delivery that have helped to
shape Western systems of health care delivery in the United States.
5. Describe trends and challenges of accessibility and financing facing health care
delivery systems around the globe.
6. Discuss factors prompting a renewed interest in traditional healing systems
7. Briefly describe factors affecting health care delivery for rural and urban aggregates.
There are many global concerns that have a significant impact on health and well-being
of people and the planet. Ethical and other issues associated with these concerns call for
both personal and professional responses from nurses at local, national, and international
levels. Examples of these issues include Earth health, natural and other disasters,
displaced persons, famine and malnutrition, child labor, use of torture, war and violence,
genocide, unexploded bombs and land mines, pollution, global warming, epidemics and
drug resistant organisms, bioterrorism, and access to and financing of health care (both
modern and traditional systems). Nurses need to be aware of both overt and covert
human rights violations that are at the heart of, or result from, many of these global
concerns. Discussion of nursing role, responsibility, and ethical considerations for several
of these concerns is included in this chapter. Students are encouraged to explore and
discuss appropriate nursing role and response related to global health issues not
Earth Ethics and Health
Discussions of ethics, especially health care ethics, generally refer to principles and practices
related to human experiences, values, and ways of being in the world. Rarely is there any
consideration of ethical treatment of the other-than-human world, indeed the Earth as a whole, the
health of which is so intricately connected to human health. Our sense of relationship with the
natural world is based in our worldview or cosmology. The Western scientific perspective flows from
a worldview that holds that there is a radical distinction between humans as subjects and the
natural world as object (Berry, 1999; Swimme & Berry, 1994; Uhl, 2004). This sense of human
experience being separate from and in opposition to nature has engendered and permitted a
destructive attitude toward Earth, and supported the belief that all species and resources of the
Earth have been put here primarily for human use. One significant assumption of the Western
worldview (that is now spreading globally) is that the more we try to control and “fix” nature, the
more we are doing what is right and good. This idea is based in a view (that began emerging in the
seventeenth century) of Earth and all her inhabitants (including the human body) as a complex
machine with ordered, predictable laws. This shift from an organic understanding of reality where
everything is alive, to a mechanistic view of reality, engendered the belief that humans have a right
to do anything they want with nature. Such an attitude results in little sense of ethical responsibility
toward the other-than-human world. To the contrary, it has allowed us to turn a blind eye to our
complicity in the exploitation of the planet. After several hundred years of demoting the natural
world to a collection of material objects available for exploitation, we are now realizing that the
complete disregard for the realities of ecological systems and the limited capacity of the natural
world to sustain such exploitation and destruction are contributing to the ill health of humans and to
the planet itself.
When we destroy the source of our life and sustenance, our health (physical, mental, emotional,
and spiritual) suffers. Indigenous peoples continue to teach what many people in the West are only
now beginning to remember, that all things are connected, that we belong to a whole universe, not
just to a city, culture, or nation. They also remind us that, as part of the interconnected web of life,
what we do to the Earth we do to ourselves. Indigenous peoples, mystics of many traditions, and
contemporary scholars understand the world to be a seamless garment in which there is no
separation between humans and nature, the sacred and the secular. They also recognize that we
cannot have healthy minds or communities without healthy land and environment (Nelson, 2004).
Understanding that we are all one single, sacred, Earth community, we need to recognize the
interdependence and unity of all in the natural world, and appreciate that all species have an
intrinsic right to exist. We need to move beyond a human-centered focus, begin to relate to the
Earth community as having core value in itself, and incorporate Earth ethics into our nursing ethics.
When we understand that, as humans, we are only one part of the interconnected Earth community,
we recognize that our ethical principles must aIDress the integrity and health of the entire
community of life, and we understand the moral imperative to apply principles of beneficence,
nonmaleficence, and justice to our treatment of the whole Earth community. This in no way
diminishes human rights, rather it augments human well-being by fostering the rights of humans to
live within healthy ecosystems and receive the life-supporting benefits of the diversity, community,
and beauty of the natural world.
Earth health is a critical global issue because, as noted above, we cannot be healthy if the Earth
is not healthy. The manipulation of nature through scientific and technological exploration has
brought many benefits to human health, life, and general well-being. These benefits, however, have
come with a high price—a disruption of the life systems of Earth, violence toward and degradation
of much of the natural world, and disruption of both the human and bioregional communities. These
disruptions have led to poisoning of the air we breathe, the water we drink, and the soil and seas
that provide us food. Examples of health problems or potential problems related to disruptions of
the natural balance in nature include asthma; birth defects; autism; deformed frogs; trees dying
from acid rain; toxins in air, water, soil, and human tissues (including breast milk); drug-resistant
organisms; and malnutrition. Recognizing that some health care practices and products can harm
both humans and the environment (during manufacture, use, or disposal), nurses are taking a
leadership role in issues of environmental health (Nightingale Institute for Health and the
Environment, 2002; Sattler & Lipscomb, 2003).
Environmentally responsible health care requires awareness and action at many levels. One
level is seeking to move beyond the symptoms of an illness to aIDress the source of the health
concern. This may need to be done on an individual, community, or global level. The impact of
smoking and second-hand smoke on asthma and pregnancy outcomes is one example of linking an
environmental pollutant to a health concern and taking action to decrease the pollutant. Many
health problems are related to toxic chemicals and other pollutants in the environment. These
pollutants come from many sources such as industrial production, everyday use in homes, heath
care and other institutions, manufacturing, agribusiness, waste disposal, and military actions. We
take these chemicals into our bodies through the food we eat, the water we drink, the air we
breathe, and through our skin. It is alarming to realize the impact of these toxins on human health;
for example, human breast milk has become one of the most toxic of foods (Lerner, 2004; Uhl,
2004)! AIDressing the source of these toxins requires action on the personal level (such as
responsible use and recycling of plastic), the professional or local level (such as reducing the use of
and providing for the responsible disposition of disposable plastic equipment in the hospital), and at
the global level (such as working for legislation that mandates industry to provide a process for
recycling components of disposable products that they manufacture in a way that does not create
Nurses need to continue to be proactive in aIDressing the impact of the health care system on
the health of the environment. This includes considerations such as attention to the health impact of
chemicals found in products used in health care institutions, how the institution disposes of toxic
and other waste, the proper disposal of unused or outdated medications, the impact of antibiotics,
hormones, and chemotherapy that get into water and soil through human waste, and unnecessary
water and electric consumption. Nurses can take leadership roles in instituting recycling programs,
helping to develop institutional policies aimed at using energy efficient, recycled, and
environmentally friendly products wherever possible, and the like. The precautionary principle
provides a useful guide for ethically aIDressing the potential risk or harm to human health or the
environment of new products, processes, interventions, or technologies. This principle states “when
an activity raises threats of harm to human health or the environment, precautionary measures
should be taken even if some cause and effect relationships are not fully established scientifically”
(Raffensperger, 2004, p. 44). The precautionary approach affirms that when there is reasonable
suspicion of harm and scientific uncertainty regarding cause and effect, people have a duty to take
action to prevent harm. With this approach, the developer or proponent of a product must provide
sufficient information about and reasonable assurances of its safety before it can be marketed.
(Currently the burden of proof of the harmfulness of a product lies with the public or government,
generally after the product is already in use.) The precautionary approach suggests action steps
that include setting goals, examining all reasonable alternatives for achieving the goal and choosing
the least harmful way, monitoring results, heeding early warnings, making mid-course corrections
as needed, and assuring that all decisions include the affected parties and be open, informed, and
democratic (Montague, 2005; Raffensperger, 2004). The ultimate goal of the precautionary
approach is to determine how little harm is possible with a new product or development.
The Earth Charter and Nursing
The Earth Charter (http://www.earthcharter.org) can provide guidance to nurses and others for
promoting ethically responsible relationships with Earth and the global community. This charter is a
people’s treaty resulting from a decade long, worldwide, cross-cultural conversation about shared
vision and goals for global interdependence and shared responsibility for the well-being of the
human family and the larger living world. As a declaration of fundamental principles for building a
just, peaceful, and sustainable global society, the Earth Charter recognizes that issues of human
rights, environmental protection, equitable human development, and a culture of peace are
interdependent and indivisible. This Charter provides a framework and ethical vision for aIDressing
these issues. The following is a summary of the principles set forth in the Earth Charter:
Respect and care for the community of life, which includes
Respecting Earth and life in all its diversity
Caring for the community of life with understanding, compassion, and love
Building democratic societies that are just, participatory, sustainable, and peaceful
Securing Earth’s bounty and beauty for present and future generations
Ecological integrity, which includes
Protecting and restoring the integrity of Earth’s ecological systems with special concern for
biological diversity and the natural processes that sustain life
Preventing harm as the best method of environmental protection and, when knowledge is
limited, apply a precautionary approach
Adopting patterns of production, consumption, and reproduction that safeguard Earth’s
regenerative capacities, human rights, and community well-being
Advancing the study of ecological sustainability and promoting open exchange and wide
application of the knowledge acquired
Social and economic justice, which includes
Eradicating poverty as an ethical, social, and environmental imperative
Ensuring that economic activities and institutions at all levels promote human development in
an equitable and sustainable manner
Affirming gender equality and equity as prerequisites to sustainable development and ensuring
universal access to education, health care, and economic opportunity
Upholding the right of all, without discrimination, to a natural and social environment
supportive of human dignity, bodily health, and spiritual well-being, with special attention to the
rights of indigenous peoples and minorities
Democracy, nonviolence, and peace, which includes
Strengthening democratic institutions at all levels and providing transparency and
accountability in governance, inclusive participation in decision making, and access to justice
Integrating into formal education and life-long learning the knowledge, values, and skills
needed for a sustainable way of life
Treating all living beings with respect and consideration
Promoting a culture of tolerance, nonviolence, and peace
Ask Yourself: What Is an Ethic of Care for the Earth?
What does your culture teach about relationship with Earth and the other-thanhuman
part of a global community of life?
How do you see principles of beneficence, nonmaleficence, and justice reflected in
the Earth Charter?
What can you do, personally and professionally, to promote environmentally
conscious practices in your local area and health care setting?
What do you see as the role of nursing in developing and promoting an ethic of care
for the Earth?
Disaster—Nursing Response and Ethical Considerations
Throughout the world nurses play an important role in providing emergency care and in meeting the
on-going humanitarian needs of people affected by disasters. Disasters are generally described as
suIDen events of massive proportion that result in large numbers of victims, displacement of
people, material damage, disruption to society, or a combination of these (World Medical
Association [WMA], 1994). Disastrous situations around the world may be linked to suIDen events
and require long term as well as immediate interventions include drought, famine, and epidemics
(such as HIV/AIDS). Disasters may be termed natural (such as hurricanes or tsunamis),
technological (such as major chemical leaks), or accidental (such as a ship capsizing). The
proportion of the disaster may be due to a combination of these factors. For example, Hurricane
Katrina might well be termed a natural disaster; however, the weakness of the levy system that
contributed to the major flooding of New Orleans was a technological disaster. Another example is
human alteration of the land through activities such as massive logging and deforestation that
contributes to the severity of some flood related disasters. Scientists see a link between the
increase in the number and severity of natural disasters over recent years and climate change,
which is occurring in great part through human activity (Uhl, 2004).
Emergency and continuous health care are essential parts of any disaster response. Disasters,
from the health professional’s view, are situations in which there is an often suIDen, unforeseen,
imbalance between the needs of people whose health and well-being are threatened, and the
resources and capacity of the health care system to meet these needs (WMA, 1994). Many health
related problems arise in a disaster. Disasters require prompt action, yet responders must often
deal with inadequate supplies and resources, and the need to get to victims who are in places that
may present health risks, be dangerous, or difficult to reach. The World Medical Association offers
guides for ethical practice for physicians in a disaster situation that are summarized below. These
apply as well to nurses. In the emergency phase, prioritizing treatment and management, or triage,
is the first ethical consideration. Triage must be done quickly and by an experienced person (often
a nurse) who is aware of available resources. Based on medical needs and intervention
capabilities, victims are separated into groups of those who can be saved and those whose
condition exceeds the available therapeutic resources. Those who can be saved are separated into
groups of those whose lives are in immediate danger and require urgent attention, those who are
not in immediate danger and who need urgent but not immediate attention, those needing only
minor treatment, and those with primarily psychological trauma. Because of the nature of trauma,
regular reassessment of victims in each group must be done. Perhaps the most difficult ethical
consideration of triage is the sense of abandoning a person whose injuries or care needs are
beyond the available care. In the aftermath of hurricanes Katrina and Rita a number of nurses
reported having to make very difficult decisions about which patients to save when electricity,
medications, and other needed supplies and equipment were no longer available. The ethical
stance in these situations is to save the greatest number of persons who have a chance of
recovery, restrict morbidity to a minimum, and do as much as possible to show compassion and
respect for those who are dying.
Ethical care of victims in disaster requires nurses to provide impartial assistance to every victim
without waiting to be asked, incorporating emotional as well as technical care. Nurses need to
obtain a person’s consent and aIDress cultural differences as often as possible. Triage decisions
should be based solely on a person’s emergency status and not on any non-medical criteria.
Nurses need to respect cultural customs, religious practices, and other traditions, especially those
associated with dying, mourning, emotional and psychological response and needs. Other
considerations are to assure confidentiality as much as possible, particularly when dealing with
media and other third parties, and to be objective and respectful of the emotional and political
climate associated with the disaster.
Nurses need to be aware of and prepared to intervene with health needs beyond the emergency
response to a disaster. Principles of humanitarian action basic to this care include meeting critical
human needs and restoring personal dignity. Critical human needs that may become serious
problems during and following a disaster include nutrition (availability, quality, and special needs of
children), economic security, environmental health (water, sewage, air quality, and vector control),
communicable disease control, emotional and mental health (including attention to rape and other
forms of violence), basic health care (both preventive and curative), family and social support.
Disaster preparedness is becoming a very important set of skills for nurses worldwide. Students are
encouraged to explore the resources related to disaster preparedness at the websites of the
International Council of Nurses (ICN)—http://www.icn.ch/disas_relatedpubs.htm, and of the
International Committee of the Red Cross (ICRC)—http://icrc.org.
Displaced Persons and Victims of Armed Conflict
In the past decades disasters, wars, political instability, and armed conflict have forced growing
numbers of people worldwide to become refugees or displaced persons. Refugees are persons
who have fled their countries and who cannot or do not want to return due to well-founded fears of
death or persecution because of their religion, race, political opinion, nationality, or membership in a
particular social or ethnic group. Internally displaced persons are those who, because of war,
persecution, or other threats, have been forced to leave their homes, but who have not crossed an
internationally recognized border (International Council of Nurses (ICN), 2006). Victims of major
disasters and those in areas of famine or severe economic upheaval can become displaced
persons either temporarily or long term. Displaced persons often have serious health and social
problems related to deprivation (including basic human rights), physical hardship, stress, poor
nutrition, and generally poor health status. Displacement often separates family members, cuts
people off from community support, employment, educational opportunities, and cultural ties.
Refugee settlements are often overcrowded and may lack sufficient resources, including food and
sanitation, to meet basic necessities and health care needs. The majority of displaced persons
around the world are women and children. The conditions in refugee settlements engender
emotional cruelty and gender specific violence such as rape, sexual abuse and harassment,
spousal battering, and forced prostitution, and may also give rise to political unrest, particularly
when internment in such camps becomes long term.
Although international humanitarian law provides for protection of civilians in the time of war,
large humanitarian groups such as the ICRC and United Nations organizations must have the
permission of the ruling power in order to work in a country. Humanitarian aid often is unavailable to
internally displaced persons, who may also be victims of repressive governments. These people
may be left without basic necessities to suffer and die because the ruling government persecutes
the group in various ways, provides no assistance, and denies permission for outside aid. The
current situation and resulting genocide in Sudan is an example of such treatment of internally
Nursing involvement with refugees and displaced persons can occur at levels of emergency
needs, care and maintenance, and seeking ongoing solutions. The ICN (2006) suggests a number
of action areas for nursing involvement with issues of displaced persons. These include raising
public awareness and lobbying governments regarding the situation, identifying nursing and health
needs of displaced persons and mobilizing resources to aIDress these needs, assisting with
emergency and resettlement programs, planning for provision and evaluation of health services
provided for displaced persons, implementing educational programs for nursing personnel, and
assisting nurse refugees. Recognizing that we live in a global community, principles of beneficence,
justice, and respect for human dignity compel nurses to advocate for those who are suffering both
close to home and globally.
Think About It: Nursing Response to the Plight of Displaced Persons
Baroness Cox of Queensbury (Interview, 2003), former co-editor of the International
Journal of Nursing Studies, is actively involved in international humanitarian work. She
calls for nurses to aIDress ethical, legal, and professional implications of the plight of
displaced persons worldwide through the following questions.
If nursing is concerned for all humanity, why are we silent when vast numbers of
people are left to suffer and die unaided?
Should nursing not be raising the issue of denial of access to those suffering under
Where is the nursing profession’s voice urging governments to press repressive
regimes to allow humanitarian and human rights organizations access to groups in
need in their countries?
How can nurses use professional conferences, journals, and media to try to find
professional, legal, and ethical solutions to these problems?
If nurses, who have a professional mandate to advocate for those who are suffering,
remain silent, who else will speak? (p. 445)
How would you respond to Baroness Cox? How would principles of beneficence, justice,
and respect for human dignity guide your response?
How do her suggestions compare with recommendations of the ICN?
What action steps are needed individually and as a profession to aIDress these issues?
War and Violence
We live in a troubled world, perhaps made more so by ease of global travel and instant electronic
communication. Conflict, violence in many forms, and war touch our lives in many ways, either
directly if we live in an area experiencing the violence, or indirectly through the media or the
presence of family or friends in war-torn areas. We cannot escape the impact of war and violence
on our lives, nor can we escape the need, as nurses, for an appropriate ethical response to these
realities. Inherent in national and international codes of nursing is respect for life and dignity of
people, and adherence to principles of beneficence, nonmaleficence, and justice. In the face of
modern warfare and increasing acts of violence worldwide (including torture and terrorism), we
need to ask ourselves what the ethical stance of nursing needs to be.
As noted in earlier chapters, the principle of beneficence directs nurses to do good and prevent
or remove harm. This includes defending and protecting another’s rights, seeking ways to keep
people out of harm’s way, and intervening to assist if the person is in danger. Nonmaleficence
directs nurses to do no harm, which includes the directives not to inflict suffering or to kill another.
Justice refers to fair and equitable treatment of individuals regardless of their backgrounds. Fair,
equitable, and appropriate distribution of resources in society is termed distributive justice.
Applying these ethical principles to issues of war and violence raises many ethical considerations,
which are discussed briefly here. Students are urged to pursue further reflection and discussion
about these critical global issues.
Precepts of doing good, avoiding harm, and preventing or removing harm impels nurses to
understand the effects of war and violence in order to know what and where the needs are and how
to intervene. One tragic effect of modern warfare is that frequently civilian casualties (especially
women and children) are more extensive than those of the soldiers (Tschudin & Schmitz, 2003).
Even after a war is over, unexploded land mines and bombs left in the region continue to create
casualties. The devastating effects of war and violence affect individuals and society and include
physical, emotional, spiritual, and social components. Physical and emotional trauma sustained in
war is compounded by poverty, destruction of societal infrastructure (such as roads, sanitation, and
communication), spread of infectious diseases, sometimes in epidemic proportions, and strain on or
destruction of resources necessary to meet basic health care needs. Traumas that have become
common in armed conflict around the world such as rape, torture, and maiming, and the stress of
displacement and having to rely on charity for basic needs contribute to the increase of health
concerns such as hypertension and post traumatic stress disorder. Fear, depression, insomnia,
flashbacks, and nightmares are part of the often life-long psychological fallout of war and violence.
An example of this is a man who survived the Nazi Holocaust and moved to a small town in the
United States after World War II. He became a successful businessman and was well respected in
the community. He owned a nice house in a friendly and safe neighborhood, but rarely lived there
because he felt insecure there. He lived instead (until his death at age 82) in a small apartment,
with several locks on the door, above a store in the downtown area because of fear that someone
would come for him in the night.
Environmental degradation resulting from war and armed conflict includes soil and water
pollution, destruction of crops, trees, other vegetation and animal habitat, and general ecological
disturbances. This affects the ability of the land to support the needs of the people for even the
basic requirements of food and water. A country’s resources are strained and possibly depleted by
warfare, limiting its ability to provide for the basic needs of its people. The lack of care and the
physical and emotional traumas sustained during the war can cause the impact of war to affect a
person’s health throughout life. The cost of war includes not just the resources needed for the
military action, but also the impact on the lives and health of individuals and communities, and the
resources needed for cleaning up, rebuilding, and repairing the various levels of devastation
caused by the war.
Nurses have an ethical responsibility to work to prevent war and conflict and the consequences
of devastation that they cause. The response to war and violence must move beyond local and
national considerations and embrace a global consciousness. This response requires taking
leadership roles at the national and international levels “advocating the prevention of conflict,
developing and teaching nonviolent ways to resolve conflict, being aware of international issues of
professional concern, learning how to exercise the profession’s political voice, and making
politicians and governments aware of the devastation and misery caused by aggression and its
drain on national and international economic, ecological, humanitarian, and emotional resources”
(Tschudin & Schmitz, 2003, p. 358).
Understanding that world peace is a prerequisite for developing, fostering, and maintaining
health, the ICN (2003) affirms the ethical responsibility of nurses to eliminate threats to life and
health caused by weapons of war and conflict. The ICN calls on national nurses’ associations to
work toward elimination of these weapons and land mines and to work to prevent the
consequences of all types of weapons. Action steps that they pose for nurses individually and
collectively include educating the profession and the public about the social, economic, and
environmental consequences of weapons that cause large-scale devastation, collaborating with
human rights and health groups, disaster prevention agencies, the media, and other groups in
lobbying manufacturers and governments against the production, distribution, and use of these
weapons, developing strategies for taking action to reduce the threat of these weapons, and
actively participating in dis
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