The threefold increase in the cesarean birth rate in the United States during the last ten years has caused much concern among the general public and some medical professionals. Nurses particularly have shared this concern as the scope of nursing practice has expanded and nurses increasingly see themselves as patient advocates. Obviously, not all cesarean births are unwarranted. The procedure may be indicated if there is maternal or fetal risk during labor, if attempted induction of labor fails, and/or if an emergency mandates immediate delivery which is not possible or suitable vaginally.

A recent review of over 1,000 U.S. and foreign research articles cites three general reasons for the increasing cesarean birth rate: use of the operation for breech presentations and for repeat sections; the need for early intervention due to fetal distress as determined by the increasing use of fetal monitoring; and physicians' fear of malpractice suits. The first two reasons are matters of medical controversy.

Nurses often administer drugs to patients for treatment and research purposes, at the direction of physicians, without knowing their legal responsibilities. Following a doctor's orders is not an adequate defense for a nurse against a lawsuit based on the administration of a drug not approved by the Food and Drug Administration (FDA); administration of a drug approved by the FDA, but approved only for a different purpose; or administration of a drug without the informed consent of a patient. Considerable confusion exists about a nurse's legal obligations in administering “new drugs,” and the purpose of this article is to provide some clarity.

The recent Supreme Court decision in the Davis case, which allowed a federally-assisted college to exclude a severely hearing impaired woman from its registered nurse training program, has caused great concern among handicapped people and their advocates. Institutions of higher education also have reason for dissatisfaction with the decision since it fails to provide sufficient guidance for those recipients of federal funding to measure their compliance with section 504 of the Rehabilitation Act of 1973. A letter dated October 5, 1979, from Patricia Harris, Secretary of Health, Education and Welfare (HEW), to college presidents is the latest official statement concerning the decision.

Concern for one's moral integrity is often a part of discussions about moral conflicts in health care. The presumption is that moral integrity is good, even though the full meaning of the concept and its relative worth are not completely understood.

The word “integrity” comes from the Latin integritas, which referred to a state of completeness or wholeness and a quality of purity. The subject of integritas included all of life. More recent understandings of integrity are limited in scope to specific areas of life, though the early meaning of an unimpaired condition has survived. But the scope of integrity is commonly limited to a firm adherence to a code of moral standards.

On July 1,1980, at four major medical institutions across the United States, the National Cancer Institute began testing Laetrile on cancer patients on whom all other therapy has failed. The study calls for 200 patients to receive the drug, along with a natural food diet. Results should be known in two years, and should demonstrate once and for all whether or not Laetrile has any cancer inhibiting effects. The study was undertaken primarily because of the large amount of publicity proponents of Laetrile have generated over the past five years, rather than any independent evidence that Laetrile may be an effective anticancer agent. Its commencement, however, provides a useful opportunity to review the legal status of Laetrile, and to suggest a possible approach to the controversy it has caused.

The social phenomenon known as professional nursing is kaleidoscopic. Nursing is embedded in an intricate network of relationships at all levels. This precludes any simple answer to the question of responsibility in setting limits to professional autonomy. It is useful to examine some of the pieces that one puts into one’s kaleidoscope to look at the question. Asking any question which involves multiple relationships risks finding several possible answers which then require significant decisions and choices having farreaching implications for individuals and groups. “Solutions” often challenge tenaciously held assumptions and values: this question is no different.

Anyone who has ever prepared a college of nursing catalogue has had to engage, if only briefly and superficially, in the development of a philosophy of nursing. I would like to carry that activity a little further here in order to propose and develop a particular philosophy of nursing.

I will describe what could be called the self care philosophy. But an important distinction must be made at the outset. “Self care” usually suggests the lay revolt against professional care; often, self care is billed as an alternative to rather than a philosophy of professional health care. What then do we mean by self care as a philosophy of nursing? The philosophy is this: that nursing have as its primary ideal active assistance to individuals, families, and communities in the development and exercise of their autonomy in health matters. The concept of self care, or patient autonomy, involves two dimensions, action and agency, and the nurse provides assistance in both of these. Self care action is the health behavior that is performed.

Americans have long wanted a health care system that is accessible, comprehensive and affordable. Our failure to accomplish these goals has resulted in a resurgence of interest in national health insurance as a mechanism for increasing access, expanding the scope of services, and controlling costs.

Unfortunately, the health care industry (which is really a sick care industry) has fostered dependence on the two most expensive components of care: physician services and hospitalization. This situation has evolved from several historical themes, three of which threaten to perpetuate our inflationary system and prevent reimbursement for non-physicians:

1. 1. failure to distinguish between medical care and health care

2. 2. control of the industry by physicians and hospital administrators

3. 3. lack of recognition for and undervaluing of the services of nurses

All of these factors have reduced the health options for consumers and have been demoralizing for nurses. This discussion will focus on various ways these issues impact upon the contributions nurses can make.

Nurses confront a variety of ethical and legal issues in both practice and education, and questions of rights, obligations, and duties arise which can have life and death consequences. Questions reflect the conflict between patients' rights and professional obligations, and between the use of resources for one individual at the expense of others.

Labor relations, labor law, and the legal aspects of collective bargaining have long been of concern to nurses employed in hospitals. The basic collective bargaining policy of the American Nurses’ Association, for example, dates back to 1946, when its convention adopted an “Economic Security Program.” Unlike some other professional organizations, the ANA not only proposed a “collective bargaining” program, but also explicitly referred to it as such, as it still does. The ANA’s 1946 statement on economic security called for collective action on such traditional collective bargaining items as a 40-hour work week, higher minimum salaries, and improved fringe benefits, as well as on more uniquely professional matters such as participation by nurses in the planning and administration of nursing services.

Providing proper health care to prisoners is often more of a myth than a reality. Nonetheless, prison officials contend that the death of a prisoner due to inadequate medical care both undermines the confidence of society in the prison system, and can create an “explosive reaction” from other inmates who view the death as preventable. Therefore it is probably not surprising that when 24-year-old Kenneth Myers, serving seven to ten years at MCI Concord, a medium security prison in Massachusetts, refused to consent to hemodialysis for the treatment of chronic glomerulonephritis and uremia, prison officials went to court to obtain an order permitting them to forceably treat him.

The medical-surgical instructor was appalled when she learned that one of her students had volunteered to perform a complex wound irrigation — a procedure in which the student was thus far untrained. Throughout the semester the student had required extra supervision and guidance, and despite this her performance had been marginal at best. Written assignments were disorganized, incomplete, and revealed poor grasp of theory, while clinical skills were consistently below acceptable levels.

But the instructor was even more appalled when other faculty members opposed her decision to give the student a failing clinical grade. “Too harsh,” they said. “Give the poor kid a break.” The instructor followed her own judgment and conscience and failed the student, but never received any support for her decision from the school's administration or faculty. Some time later, in talking with faculty from other schools, the instructor learned that her experience was not unique. Others had similar problems: resistance to failing and even not-so-subtle pressures to pass students whose performance the instructor deemed to be substandard.

The title of Tom Wolfe's current best seller, The Right Stuff, refers to those qualities — manliness, fearlessness, survivability, and recklessness — that characterize successful test pilots in general, and Mercury astronauts in particular. A similar list could be compiled to characterize successful surgeons. It would likely include decisiveness, confidence, dexterity, and dedication. The list would be unlikely to include open-mindedness or a concern to present patients with all the options available for particular disease conditions.

This “self-righteous silence” has recently brought the wrath of the women's movement down on surgeons who perform breast cancer operations without informing their patients about alternatives. And in 1979 Massachusetts became the first state to enact a law requiring physicians to provide “a patient suffering from any form of breast cancer” with “complete information on all alternative treatments which are medically viable.” This column examines the reaction to the law.

Nursing has come a long way. Today's professional nurse is intimately involved in virtually all areas of our expanding health care system — in the community, in industry, in clinics, in education, in hospitals, and in government. The practice of nursing today frequently entails making and participating in important and critical decisions, as well as performing a wide variety of modern clinical functions. All of this requires a sound base of sophisticated medical knowledge and a high degree of technical skill. This is a major change from the nurse of the past, who practiced primarily within the hospital setting, doing what she was told, providing bedside "service" to patients, and rarely, if ever, asking questions or making decisions.