Marianne Hattar-Pollara D.N.Sc. FAAN

1. Religious and Cultural Moral Values Informing the Process of Ethical Decision Making of Jordanian Nurses Marianne Hattar-Pollara D.N.Sc. FAAN JNC 2010

2. Acknowledgment Many thanks to: The Jordanian Nurses Council for their continued efforts in promoting nursing education and scholarly pursuit in Jordan and in the region Special thanks to : All nursing faculty and students who in one way or another helped inform the research in this area. JNC 2010

3. Why this is important Throughout history and across cultures and nations religion has been a potent and pervasive influence on people’s worldviews, especially during times of illness. Ethical challenges arise when the religious-cultural moral values take precedence over principled bioethical values. The actual impact of such challenges is not known but very likely has negative psychological consequences on nurses’ role performance and satisfaction. JNC 2010

4. The Purpose of This Report To examine the received ethics of Jordanian nurses so as to promote ethical debate and reflection among nurses in Jordan and to inform the Jordanian nursing code of ethics. It is important to note that the ethical challenges that will be exemplified in the text of this paper are similar to those found throughout the Arab Middle East and will have important ethical implications for all of the Arab Middle Eastern. JNC 2010

5. Sources of Moral Values in Jordan Ethics in Jordan does not occupy a separate academic discipline in the sense of a discipline drawing exclusively on human reason or human experience. The religious and cultural tradition of Jordanians occupies central importance and constitutes core moral and social values to which Jordanians uphold as supreme. These core religious and cultural moral values shape Jordanian nurses ethical reasoning; the process of which is influenced by the intersection of the religious, the cultural and health systems. JNC 2010

6. Religion: Source of Moral Values Islamic religion has an extensive moral component that is utilized in resolving religious, ethical and legal issues of in all spheres of life including health and illness. The moral component in Islam is drawn from Shari'ah,whichis the scared law of Islam and consists of commandments and prohibitions. Shari’ah demands a moral existentialism of “doing right” and is concerned with both the purpose and the principles of the law. The principles of the law have particular relevance to clinical applied ethics and may have a degree of conceptual semblance to Western ethical principles of duty, justice, benevolence, honesty, and integrity, yet the purpose and the theological rationale of these principles may be entirely different from the Western philosophical principles. JNC 2010

7. Principles of Shari’ah • Shari'ah offers two fundamental principles of common good: • Istihsan: Literally means the act that which is desired for the benefit of most. Stemming from the root word Hassan (good) and it derivative hassanah (giving, donating), it can also mean offering from oneself or one’s material goods to improve or meet others needs. • Maslaha, on the other hand, has meaning at both the • Personal (Maslaha Khassa) and • Public interest (Maslaha Ammah). • While one is free to exercise personal interest as long as such interest does not pose harm to others, the importance of pursuing personal interest diminishes when it conflicts with the common or public interest. JNC 2010

8. Western Bioethics Bioethics in the United States has largely adopted the language and arguments of philosophy as the language of moral discourse in health care. Historically, normative ethics has always been the domain of religions if for no other reason than that religious persons needed ways to think about actions and relationships and to know whether or not they had erred morally. With the rise of bioethics in the 1960s, many of the early bioethicists were trained in theological seminaries, were religiously identified, and wrote from a religious perspective. It remains the case that a large number of medical ethicists writing in bioethics today continue to do so from an explicitly religious perspective. JNC 2010

9. Western Bioethics: Phases of development in the US (Fox. 1990) • Three Phases: • The first phase centered on the voluntary consent to participation of human research subjects. • The second focused on end-of-life issues including definitions of life, death, personhood, the use of technology at the end of life, and advance directives. • The third phase focused on access to care, cost containment, rationing, and the allocation of medical resources. JNC 2010

10. Western Bioethics: Representing Western Medicine The major representative issues that arose in these three phases have included informed consent, protection of human subjects, protection of vulnerable subject groups, definitions of personhood, allowing infants with Down’s Syndrome to die, privacy and confidentiality, withholding or withdrawing life-sustaining treatment, treatment futility, access to care, cost of care, restriction of resources received by elderly persons, allocation of donor organs, and the use of genetic materials, genetic patents, and genetic prejudice. These issues are specifically representative of the practice of Western allopathic medicine. That is to say that the moral discourse that has predominated has focused on Western systems and medical practice; other systems of medicine and the issues encountered by non-physician health professionals have received substantially less treatment in the dominant bioethical literature in the US. JNC 2010

11. Bioethics: The Jordanian Case • Concerted efforts were made to introduce Western Bioethics in curriculum of nursing and medical programs. • Other Motivating factors Include: • developing Jordanian health care system for medical tourism and the need to respond coherently to Western clients bioethical health care needs. • the desire to establish the same level of bioethical knowledge between Jordanian health care providers and their Western counterparts. JNC 2010

12. The Study • The purpose of this study is : • To critically examine the native received ethics of Jordanian nurses through examination of religious moral prescription and proscriptions and through analysis and examinations of the dominant cultural moral values and norms. • To critically examine Jordanian nurses’ received ethics so as to explicate the areas of agreement and the areas of discord between the native religious-cultural moral principles with that of Western bioethical ethics. JNC 2010

13. Methods • Design: Survey • Sample: Non-probability sampling of students in the undergraduate an program in a local university • Measurements: Demographics and open ended interview schedule. The questions were clustered around the following areas: • Training in biomedical ethics • Encountered ethical dilemmas • Sources of ethical authority utilized JNC 2010

14. Findings: Demographic Data Sample size: 27 Religion: All are Muslim women ranging in age from 22 to 44 with an average age of Income : 33% has an income of less than 500 JD, 44% has an income of less than 1000 JD, the remaining ranged from less than1500 to 2000 JD with only 7% earning a family income of over 3000 JD Years in clinical experience ranged from 2 to 24 with an average of 7.2 years Years in educational settings ranged from 1.5 to 20 years with an average of 3.85 Level of education: About 66% are currently completing the MSN program and the remaining are in the Ph.D. program Formal training in nursing ethics: 85% had formal training in bioethics JNC 2010

15. On ethical dilemmas and decision making • Cluster of responses: • Nurses’ input is not taken into account • Nurses are not part of the decision making • Are required to carry out orders despite opposition to ethical decision made • There is no system in place to manage ensuing distress or role conflict of health care providers JNC 2010

16. On Bioethical Theories Ethical theories provide the rational ground for moral reasoning, however these are in direct conflict with own belief and values When ethical decision making clashes with religious belief, the process is distressing and demoralizing. JNC 2010

17. On Principled Ethics Jordanian nurses listed doing good, doing no harm, justice and fairness Jordanian nurses failed to list respect for autonomy Yet, when asked which principle they appeal to, when conducting moral or ethical reasoning, they spoke about their own religious belief and values JNC 2010

18. Where Do We Go From Here? For the purposes of nursing ethics, the nursing profession must come to a better and more knowledgeable understanding of the ways in which local culture and religious beliefs intersect with ethics. For the purpose of patient decisions, nursing and other health disciplines must engage in exploring the ways in which religions informs, critiques and enlarges moral discourse within health care. For the purpose of health care providers, a system must be put in place to achieve the above objectives and to safe guard for potential distress and demoralization. JNC 2010