Symphonological bioethical theory

Nursing

Symphonology holds that a nurse or any other health care professional acts as the agent of the patient. Using her education and experience, a nurse does for her patient what he would do for himself if he were able. Nursing cannot occur without both nurse and patient. “A nurse takes no actions that are not interactions” (Husted & Husted, 2001, p. 37). The nurse’s ethical responsibility is to encourage and strengthen those qualities in the patient that serve life, health, and well-being through their interaction (Fedorka & Husted, 2004).

Agency is the capacity of an agent to take action toward a chosen goal. A nurse as agent takes action for a patient, one who cannot act on his own behalf. The shared goal of a nurse and a patient is to restore the patient’s agency. The nurse acts with and for the patient toward this end.

Person or patient

The Husteds define a person as an individual with a unique character structure possessing the right to pursue vital goals as he chooses (Husted et al, 2015). Vital goals are concerned with survival and the enhancement of life. A person takes on the role of patient when he has lost or experienced a decrease in agency, resulting in his inability to take the actions required for survival or happiness. The inability to take action may result from physical or mental problems or from a lack of knowledge or experience (Husted & Husted, 1998).

Health

Environment or agreement

The environment established by symphonology is formed by agreement. “Agreement is a shared state of awareness on the basis of which interaction occurs” (Husted et al, 2015, p. 32). Agreement creates the realm in which nursing and all other human interactions occur. Every agreement is aimed toward a final value to be attained through interactions made possible by understanding.

The health care professional–patient agreement is formed by a meeting of the professional’s and the patient’s needs. Their agreement is one in which the needs and desires of the patient are central. The professional’s commitment is defined in terms of the patient’s needs. Without this agreement, there would be no context for interaction between the two. The relationship would be unintelligible to both (Husted & Husted, 1999).

Symphonology theory is not a compilation of traditional cultural platitudes. It is a method of determining what is practical and justifiable in the ethical dimensions of professional practice. Symphonology recognizes that what is possible and desirable in the agreement is dependent on the context.

The context is the interweaving of the relevant facts of a situation—the facts that are necessary to act upon to bring about a desired result (Husted & Husted, 2001). There are three interrelated elements of context: the context of the situation, the context of knowledge, and the context of awareness. The context of the situation includes all facts relevant to the situation that provide understanding of the situation and promote the ability to act effectively within it. The context of knowledge is an agent’s preexisting knowledge of the relevant facts of the situation. The context of awareness represents an integration of the agent’s awareness of the facts of the situation and her preexisting knowledge about how to most effectively deal with these facts (Husted & Husted, 2008).

Rights

The Husteds describe rights as the fundamental ethical element. Traditionally, rights are viewed as a list of options to which one is entitled, a list of items or actions to which one has a just claim. Symphonology holds rights as a singular concept. It is the implicit, species-wide agreement that one will not force another to act, or take by force the products of another’s actions. Rights are viewed as the critical agreement among rational people, the agreement of nonaggression (Husted & Husted, 1997a). This agreement emerged as humans became rational and developed a civilized social structure. A nonaggression agreement is preconditional to all civilized human interaction. It serves as a foundation on which all other agreements rest. The formal definition is as follows: “the product of an implicit agreement among rational beings, held by virtue of their rationality, not to obtain actions or the products of actions from others except through voluntary consent, objectively gained” (Husted et al, 2015, p. 20). The operation of this is evident in human interaction.

Symphonology theory can ensure ethical action in the provision of health care. Agreement is the foundation of symphonology. Agreements occur based on the implicit understanding of human rights. The understanding of nonaggression that exists among rational persons constitutes human rights. This understanding makes negotiation and cooperation among individuals possible.

Ethical standards

Ethical standards have been the benchmarks of ethical behavior. The standards include terms familiar to health care professionals such as beneficence, veracity, and confidentiality. However, the Husted et al, (2015) have conceived new meanings for ethical standards that correspond to the foundational concepts of symphonology: the person as a unique individual and the use of insight and discernment in addition to reason and rationality to achieve a deeper understanding.

Traditionally, bioethical concepts have been used to guide ethical action by mandating concrete directives for action. For instance, the concept of beneficence conventionally maintains that one must see that no harm comes to a patient. However, it is not always possible to predict how and when harm will occur, making adherence to this directive an unrealistic goal. The concept of beneficence, viewed as a mandate, could also imply that defending oneself against a physical attack is unethical. Similarly, veracity, or truth telling, holds that one must always speak the truth regardless of the consequences. Therefore it is unethical to withhold potentially harmful information, regardless of the consequences. Adhering to veracity may interfere with one’s commitment to beneficence. Clearly, ethical standards taken as concrete directives do not allow for the consideration of context.

Just as the bioethical standards are not to be considered as concrete directives, so too, they are not distinct entities. Each standard blends with the others as representative of the unique character structure of the individual (J. Husted, personal communication, March 2004). As stated earlier, recognition of these standards is preconditional to the implicit patient–health care professional agreement. When recognized and respected in each individual, these human qualities and capabilities form the basis for ethical interaction. When they are disregarded, the context of the situation is lost. Interaction is then based on whatever is served by concrete directives or on the whim of the participants.

Certainty

There are circumstances in health care when a patient is unable to communicate his unique character structure, as in the case of an infant or a comatose patient. Health care professionals also interact with individuals from different cultures for whom a common language is lacking. In these cases, the bioethical standards can provide a measure of certainty when knowledge of an individual’s unique character is unobtainable.

“If you know nothing whatever about an individual’s uniqueness, then you are justified in acting on the basis that, as a member of the human species, he shares much in common with every other individual”

(Fedorka & Husted, 2004, p. 58).

These commonalities are the bioethical standards. Each person needs the power to sustain his unique nature; the power to be objectively aware of his surroundings; and the power to control his time and effort, to pursue benefit, and to avoid harm. Lacking other information, nurses and health care professionals are justified to do all they can to restore these powers to the individual.

Decision-making model

The Husteds described the ultimate application and practice of these assumptions by health care professionals in the following way. The professional will come to understand and work from the philosophy that:

“My patient’s virtues (autonomy) are such that he is moving toward his goal (freedom) in these circumstances (objectivity) for this reason (beneficence). My virtues (autonomy) are such that I must act with him (interactive freedom) to assist him (his freedom) within the possibilities (of beneficence) in his circumstances to achieve every possible benefit that can be discovered (by objective awareness).”

Practice

The Husted symphonological model for ethical decision making (Husted & Husted, 2001) was developed as a practice model for applying the concepts of symphonology. This model, stressing the centrality of the individual and the necessity of reason directed by context, is vital in existing and emerging health care systems. The model provides a philosophical framework to ensure ethical care delivery by nurses and all other disciplines of health care. Unlike traditional models, the symphonological model provides for logically justifiable ethical decision making. The North Memorial Medical Center in Robbinsdale, Minnesota, adopted the model for use by their nursing ethics committee.

The call to care in nursing is central to the profession. Hartman (1998) asserted that caring is demonstrated when nurses recognize that the bioethical standards are so intertwined with caring that together they provide a perfect circle of ethical justification. Enns and Gregory (2006) proposed that nursing is losing the essence and practice of caring because of the changing health care environment. Symphonology offers a practice-based approach to care, as follows:

“A practice-based approach is derived from, and therefore is intended to be appropriate to the situation of a patient, the purpose of the health care setting, and the role of the nurse. The more an ethical system restricts practice based on abstract principles the more nurse and patient become alienated from each other.”

(Husted & Husted, 1997b, p. 14)

Many nurses practice within systems bound by protocols and critical pathways. Using a symphonological approach can ensure that nursing practice remains ethical and does not become prescriptive. This is particularly important when considering making decisions for those who can no longer make decision for themselves (Gropelli, 2005). Often clinical emergency patients are unable to participate in decision making. Symphonology offers a method of ensuring that ethical conclusion and actions are based on the best interests of the individual (Fedorka & Husted, 2004).

Education

As symphonology is disseminated, it is easy to integrate it into nursing education. Ethics is increasingly being addressed throughout nursing curricula rather than as a separate topic, particularly for advanced nursing students. The broad applicability for symphonology makes it an excellent framework for nursing curricula. Beginning students can easily grasp and apply the theoretical concepts. Using this theory as a basis for nursing interactions directs the student in ethical practice from the beginning of learning nursing practice. The concept of context can be used as the basis for assessment. The bioethical standards direct the student in choosing appropriate approaches, timing, and type of interventions for each patient. Because of the holistic approach and central concern for the patient, symphonology can be incorporated easily into existing nursing curricula.

Brown (2001a) addressed the importance of ethical interaction between nurse educator and student. The agreement in this case is more explicit, because both parties are more aware of the commitments and responsibilities. Recognizing the bioethical standards in both the educator and the student serves to direct ethical actions between them. Above all, the educator and student recall that the educator–student–patient agreement is central to the learning process.

The Husted model not only identifies and organizes professional values and ethical principles for learners, but it also helps the educator to develop a consistent professional ethical orientation. Cutilli (2009) used case study applications with the symphonological theory approach to patient and family education. Burger et al. (2014) used the Husted model to examine incivility among faculty in education. The model provides a mechanism to explore interactions based on the bioethical standards and facilitates ethical decision making within interactions. This led to the conclusion that the integration of ethics into academia is essential for nursing education.

Administration

Health care administrators make decisions at several levels. They have a responsibility to the community at large and the financial viability of the institution within the community, the employees, and those receiving care. Hardt (2004) described how administrators use the principles of symphonology to guide their decision making to produce ethically justifiable outcomes. At the community and institutional levels, one considers the needed services provided by the institution. In cases in which the services needed would not be feasible for the institution, resources within the community can be shared and supported by the institution so that needed services are available with the least amount of loss to the institution. At the employee level, the administrators are concerned with care delivery as well as interpersonal relations. Symphonology guides decision making into equitable rather than equal solutions. For example, an employer may choose to forgo the use of a harsh sanction for absenteeism when the employee is able to show extenuating circumstances that prevented her attendance. This is also true for the development of policy regarding employees’ behavior. Ethical policy provides guidelines for examining situations rather than prescribed rules with concrete directives for action. With regard to individual patients, administrators act as role models and consultants when addressing ethical issues.

Hardt and Hopey (2001) described the problematic situations that occur within managed care systems. Difficulties that have been identified include the refusal of the organization to provide care deemed appropriate by health care professionals and the inappropriate demands of patients and families. Using the principles of symphonology, health care professionals can examine the context and determine appropriate ethical actions within the implicit and explicit agreements.

Nurse administrators and managers can also use symphonology to mediate inappropriate situations between patients and nurses (Bavier, 2007)—for example, cases in which patients wish to give an inappropriate gift as a sign of appreciation to a particular nurse.

Research

Symphonology in research is useful in relation to the researcher-subject agreement. The health care professional–patient relationship is to some extent implicit, but the relationship between a researcher and a subject must be thoroughly explicit. Brown (2001c) suggested using the bioethical standards to develop an ethical informed consent protocol. Particularly when the research involves vulnerable populations, the consent of surrogates is made more acceptable and is obtained more easily if the good of the individual is made central by using the bioethical standards.

Clarity

In Ethical Decision Making in Nursing (Husted & Husted, 1995a), the authors presented the emerging concepts of symphonology and the relationships among the concepts. The book may be difficult for beginning nurses to follow, because deeper concepts meant for advanced practitioners are included along with basic ideas. The third edition, Ethical Decision Making in Nursing and Healthcare: The Symphonological Approach, begins with the basic concepts for understanding and using the theory and then moves to more advanced concepts in later sections (Husted & Husted, 2001). Along with this improved organization, the third edition shows the emergence of increasing clarity for all concepts, the bioethical standards in particular. The fourth edition provides yet further clarity using tables and figures and includes a user-friendly teacher manual.

This work challenges traditional methods of thought and requires the reader to develop a new understanding of familiar concepts. Storytelling and examples provide the opportunity to recognize and understand the importance of alternative and extended meanings for familiar terms. The conversational tone of the writing is appealing and creates a comfortable atmosphere for a complex subject.

Simplicity

The authors first challenge the truth and efficacy of traditional ideas about ethical behavior and decision making. This is a simple matter if the reader is open-minded to a different view of nursing events. As the reader accepts the challenge, the simplicity of the theory is evident. There are few concepts, and the relational statements flow logically from the definitions. The model clearly demonstrates the elements of the process of ethical reasoning and the manner in which these elements interact.

Generality

Symphonology is applicable at all levels of nursing practice and in all areas of health care. The principles can be applied between nurse and patient, researcher and subject, manager and employee, and educator and student. Health care professionals of all types can use this method to determine appropriate ethical behaviors in practice. This theory can also be applied to the process of establishing health care policy that is ethical in nature. Indeed, these principles can be applied in all walks of life, depending on the nature of the agreement between the parties involved.

Accessibility

Symphonology is a theory grounded in ethical principles and based in reality. Evidence has demonstrated support of the theory in nursing practice decision research, and the reality of the usefulness of the theory in practice is evident. Nurses and other health care professionals can easily understand the concepts and apply them in all situations. The result of using the symphonological model is a patient-centered, ethically justifiable decision.

Importance