Legislationandotherofficialframeworks

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The ethics of proximity prescribe that only a participative approach to the other person makes a moral relationship with him possible: only by participating in the other’s well-being can the ‘I’ act as a moral subject; and only as the addressee of such participation can the other appear as the moral addressee. The choice of approach is therefore defining for both parties simultaneously – for the party who takes the approach and for the party the approach is directed towards. The manner in which we view a situation decides what we see, decides the nature of the situation for us (Vetlesen and Nortvedt 1996:160).

Criticism levelled at the ethics of proximity has involved the fact that closeness and

responsibility for the local patient can set aside considerations for other patient’s with relevant needs as well as undermining our sense of global responsibility.

Nortvedt’s own view is that the ethics of proximity cannot stand alone as an ethical perspective or theory, but must be supplemented by other and more traditional ethical approaches such as virtue ethics, deontology and consequentialism. He also claims that perhaps the most significant contribution of an ethics of proximity is to gain an understanding of the basic foundations of morality (Vetlesen and Nortvedt 1996).

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health care following consultations with other qualified health personnel. The patient’s record must contain any information from his/her next of kin as well as the opinions other qualified health personnel may have given.

Health care pursuant to the first and second paragraphs may not be provided if the patient objects thereto, unless special statutory provisions dictate otherwise.

Section 4-9. The patient’s right to refuse health care in special situations (2nd and 3rd paragraphs) A dying patient is entitled to object to life-prolonging treatment. If a dying patient is incapable of communicating his or her wishes as regards treatment, the health personnel shall refrain from providing health care if the patient’s next of kin express similar wishes, and the health personnel, based on an independent assessment, find that this is also the patient’s wish and that the wish should clearly be respected.

Health personnel must make sure that a patient as mentioned in the first and second paragraphs is of full legal age and legal capacity, and that he or she has been given adequate information and has understood the consequences of refusing treatment for his or her own health.

3.2.2 The Health Personnel Act²⁵

An extract on responsible conduct is quoted directly from the Act (Norwegian Ministry of Health Care Services (HOD) July 1999) as a significant point of reference for the discussion in Chapter 6:

Section 4. Responsible conduct

Health personnel shall conduct their work in accordance with the requirements for professional responsibility and diligent care that can be expected based on their qualifications, the nature of their work and the situation in general.

Health personnel shall act in accordance with their professional qualifications, and assistance shall be obtained and patients shall be referred on to others if this is necessary and possible. If the patient’s needs so indicate, the profession shall act through co-operation and inter-action with other qualified personnel.

Upon cooperation with other health personnel, the medical practitioner and the dentist shall make decisions in matters concerning medicine or dentistry respectively in relation to examinations or treatment of the individual patient.

The fourth paragraph of this section related to this study’s discussion addresses physicians’

competence and their mandate to prescribe and provide medical treatment and to give information on such treatment:

The Ministry may determine in regulations that certain types of health care shall only be provided by personnel with special qualifications.

Distributing medication, including administering intravenous medicines, is a task for physicians. When nurses do this as part of their work, the physician delegates the task to them. Section 4 of the regulations relating to handling medicinal products governs the

25 http://www.lovdata.no/all/nl-19990702-064.html

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requirements regarding competence and training for delegated tasks and is based on Section 5 of the Health Personnel Act, Use of assistants. This can apply to administering intravenous antibiotics and intravenous pain-killing preparations etc. In hospitals these are everyday activities for nurses, whereas in nursing homes they may be tasks that are performed irregularly. Delegated responsibility encourages training and develops competence, and in nursing homes it is the duty of the enterprise director/administrator to ensure that this responsibility is safeguarded²⁶:

The enterprise manager must therefore ensure that health personnel possess and maintain the necessary qualifications for the nature of the tasks and the follow-up that is given. ‘Qualifications’ in this context means both formal and informal qualifications, i.e. professional health education, supplementary education and experience. This entails a dynamic competence requirement that totally depends on the task that is delegated.

3.2.3 National guidelines for decision-making processes for limiting the life-prolonging treatment of seriously ill and dying patients

In 2009 guidelines were published in Norway on the issue of limiting life-prolonging medical treatment (Norwegian Directorate of Health 2009). The need for such guidelines had come to light over time as a result of the medical development that makes it possible to prolong life beyond what was previously deemed natural and also achievable. The difficult ethical dilemma arose as a consequence of this development, and gradually drew attention to the need for such guidelines. Individual cases that were reported in the media led to professional debates and also revealed the need for common guidelines. The Centre for Medical Ethics at the University of Oslo and the Norwegian Medical Association have put considerable work into the guidelines, and various professional communities have been involved. The working group that compiled the guidelines was led by Reidun Førde. The target group is the specialist health service and the municipal health and care service, and the purpose is given as

follows²⁷:

The purpose of the guidelines is to quality assure the decision-making process related to initiating or discontinuing the life-prolonging treatment of seriously ill patients who have a poor prognosis and who without such life-prolonging treatment will die within a short time, i.e. within days or a few weeks. The guidelines are intended to provide both frameworks for such decision-making processes and support for treatment personnel, patients and next of kin. Since the guidelines are aimed at the entire health service, the need may arise for more detailed guidelines within individual disciplines or institutions (2009:3).

26 Unofficial translation

27 Unofficial translation

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The decision-making processes related to the issue of life-prolonging treatment are of central importance²⁸.

3.2.4 Long-term care – future challenges (Report no. 25 to the Storting: 2005-2006) This document from the Ministry of Health and Care Services (HOD)(2005-2006) legitimates increased research and investment in competence in order to ensure the quality of services for the elderly. Significant and relevant topics for this study that are discussed in the report include a holistic dementia plan, a national standard for medical services in nursing homes, end-of-life care and palliative treatment.

3.2.5 The Coordination Reform – proper treatment – at the right place at the right time (Report no. 47 to the Storting: 2008-2009)

Patients, particularly elderly patients, are dependent on the various levels of treatment being conducted in a continuous chain to ensure that each individual receives good medical treatment and care. Poor collaboration has been revealed between the levels in the Norwegian public healthcare service, and in 2009 a report to the Norwegian parliament was issued (Ministry of Health and Care Services 2008-2009). This reform was aimed at ensuring better continuity in the treatment of patients across the various levels to prevent them being shuttled from one part of the health service to another. The term “collaboration” in this context entails professional collaboration among the various professions and across institutional borders (Orvik 2004, Wilson, Coulon et al. 2005).

3.2.6 Summary

As we have seen from this overview, ethical as well as legal and clinical oriented guidelines have in later years been established within the Norwegian health care contexts. This

development of more structural and organised knowledge and research is a basis for the future quality of elderly care in which patient autonomy and shared decision-making will be

important parts of medical treatment and nursing care.

28 The guidelines give advice on including the next of kin of patients who are not competent to give consent.

They also provide key definitions, as well as many references to relevant literature

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