What Would You Do?

When teaching ethics in nursing school, Anne Davis likes to present students with hypothetical dilemmas they might face. In one scenario, a man in his 60s – a heavy smoker who lives with his son and daughter-in-law – is dying of lung cancer. Neither the man's physician nor his son have told him how ill he really is. One day, the man says to the nurse: "I can tell I'm not getting any better. Everybody keeps telling me I am, but I don't think so. I seem to be seriously ill. What do you think?" What should the nurse say or do?

Davis, 70, is no ordinary ethics professor. A quarter of a century ago, she wrote Ethical Dilemmas and Nursing Practice (EDNP), currently in its fourth edition. From the beginning, one of her goals was to help nurses develop critical-thinking skills to reason through ethical problems.

"The text was the first of what they call the 'modern' nursing ethics books, which is a way of saying it was principle-based, instead of talking about virtue," she says. "Everything before that had spoken about the 'good person,' the 'good nurse.' Ethical Dilemmas and Nursing Practice was a way of going outside the person and looking at ideas and setting up conceptual ways of thinking about ethical issues."

Facing Difficult Choices at Home and Abroad

After earning a Master's degree in psychiatric nursing from Boston University in Massachusetts, Davis worked for more than five years in psychiatric hospitals. Lobotomies and electric shock were common. "In those days," she remembers, "the assumption was that if you were a patient in a psychiatric hospital, you were not competent to know what you wanted. There was no real concept of patients' rights, and certainly not for psychiatric patients, who were considered 'crazy.'" At staff meetings, Davis recalls, "I would say, 'I don't understand why we're doing this. She says she doesn't want this [electroshock]. She says this very clearly.' They would say, 'She's depressed,' or give some other reason: 'This is the best treatment. We know what's best for her.'"

Davis holds a PhD in education from the University of California, Berkeley, and studied ethics during a year-long Kennedy Fellowship at Harvard University in Cambridge, Massachusetts. Back in San Francisco, Davis worked as an ethics consultant at the University of California, San Francisco Hospital (UCSF), in a hospice, and at other healthcare institutions. Some of the most difficult challenges arose in the 1980s, when AIDS hit San Francisco with a terrible ferocity, and doomed patients sought assistance to die.

Davis has traveled widely – lecturing, teaching, conducting research, and serving as an ethics consultant in countries as diverse as China, Nigeria, Colombia, and Norway. She has visited more than 120 countries on seven continents. An enormously personable woman, she has made friends wherever she has gone.

When she is in the United States, Davis lives in San Francisco, just a few blocks from Golden Gate Park. Her second-floor apartment is filled with objects and art collected during her travels: masks from New Guinea, an aboriginal Australian didgeridoo, Chinese calligraphy, Russian paintings, and hand-woven cloth from Kenya. Davis is particularly fond of the half-dozen museum-quality Japanese netsuke (small, intricately carved ivory figures) in her living room.

Education, Not Indoctrination

Since retiring from UCSF in 1994, Davis has spent six years in Japan, where she teaches at Nagano College of Nursing in Komegane, four hours north of Tokyo. Davis teaches everything from an introduction to nursing for first-year students to graduate courses in ethics.

Davis asks young Japanese students to discuss the elderly man who has lung cancer. In Japan, physicians and relatives usually do not tell someone that they are dying. Japanese culture, Davis says, does not hold sacrosanct the right of individuals to make healthcare decisions; instead, the Japanese consider knowledge about a serious illness to be a burden and consider it the responsibility of family members to make decisions for the person who is ill.

Davis does not encourage Japanese students to adopt Western standards, but, rather, to examine their own beliefs and assumptions. "'What would you do if a patient [asked you if he was dying]? What would you think your obligations as a nurse are? Should you go to a physician and say something? This guy's asking – he seems to seriously want to know. Would you go to the family? Would you go to the head nurse? You're the only one who has this information. Are you just going to sit on it? Do you think that's what a good nurse should do?' They begin to think."

And that is Davis's goal. "I don't think ethics asks us to agree," she says. "It does ask us to examine, and think, and engage in dialogue. There's a difference between indoctrination and education. I don't believe in indoctrination." She wrote in her preface to the first edition of EDNP: "We do not presume to indicate what is the right thinking or what actions should be taken in ethical dilemmas, but we do agree with Alfred North Whitehead, who said, 'The simple-minded use of the notions of right or wrong is one of the chief obstacles to the progress of understanding.'"

Where Do You Draw the Line?

After her time in Japan, Davis isn't sure herself that a Japanese nurse should inform a Japanese patient about his own illness. It is, after all, "their country, and their culture." For Davis, the acceptance of different ethical values is an essential part of a willingness to fully accept other cultures. But in practice, she says, it does not always happen: "In nursing school, at least, we talk about cultural pluralism, and then we talk about ethics as if they're universals. You can't have both. That doesn't fit, logically." Too often, she adds, Westerners consider their own philosophical tradition – the ethics she teaches – to be the "truth."

Yet Davis also ponders the limits of tolerance. Her own limits were severely tested several years ago, when she worked on a World Health Organization committee that examined female genital mutilation. "I happen to think genital mutilation is wrong for a whole bunch of reasons, some pragmatic and some ethical," she says. "Some people say, 'Who are you to say those people are doing something wrong?' But if you don't take a position on certain things, then anything goes – slavery, the death penalty, whatever. It's OK, as long as it's internal to a culture. Well, everything's internal to some culture.

"How do you balance being tolerant, but not of everything? If you tolerate everything, then you have no standards, no values. Anything goes. Where do you draw the line? It's a profoundly difficult question."

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