Ethics: Domestic Violence, Nurses, and Ethics: What are the Links?

Throughout our world, violence confronts us daily. We hear about it on the news. We read about it in newspapers and on the Internet. We experience it subtly and overtly in all cultures and across nations in incidents ranging from ethnic slurs to hate crimes to violence carried out in the name of ideology. Such incidents of violence tend to be easily seen as they fall within the public domain. Less visible, however, but often more devastating, is the domestic violence that occurs within the family and often against women. The International Council of Nurses (ICN) (2001) notes in a summary of research done on four continents that as many as 20 to 50 percent of all women in the studies reported experiencing partner violence. Thus, Volume 7, Number 1 of OJIN focuses on this issue of violence. But what are the links among domestic violence, nurses, and ethics? Using illustrations from the articles in OJIN, we will analyze this question through the lens of three frameworks: (a) feminist ethics; (b) nonmaleficence and its supporting rules; and (c) codes of ethics for nurses.

Feminist Ethics

Various definitions of feminist ethics exist but, overall, they share a common theme: that systematic and ongoing oppression of women based primarily on gender is morally wrong. According to Choi (1999), "Feminist ethics addresses the gap in general well-being between large numbers of women and men in both industrial and developing countries" (p. 14). The gender issue, as well as the broader social context, is also noted by Volbrecht (2002):

A feminist is a person who rejects the ways in which women and their experiences have been criticized, ignored, and devalued. A feminist also is someone who works to bring about the social changes necessary to promote more just relationships among women and men. Feminist ethics challenges perceived male biases in ethics, which have contributed to the devaluing of women's moral experience and to the subordination of women. (p. 160)

Closely related to the social changes noted by Volbrecht are the political processes needed to bring about desired changes for women, especially in health care. The relationship between the social and political processes has been noted by Silva and Kroeger-Mappes (1998). According to them,

Feminine ethicists reveal the ways in which ethical theory has been and remains embedded in certain social structures and understandings, and in political institutions. According to feminine ethicists, an understanding of social and political forces is necessary to understand and alter any moral theory's impact on and import for women. (p. 6)

We have selected two articles in this issue of OJIN to address feminist ethics. In one part of her article, Draucker (2002) addresses intimate partner abuse as repeatable and increasing patterns of violence against women by men in their attempts to gain power. She notes that because this abuse occurs in a continuing relationship, or in a newly severed one, the perpetrator may have long-term access to the abused one. Furthermore, she acknowledges the many economic and sociological factors that contribute to domestic violence and then recommends, among other actions, that nurses advocate for policies that redistribute power and wealth in the United States so that female victims of domestic violence benefit. In this sense, then, and within the framework of the previous definitions of feminism, nurses base many of their actions, perhaps unknowingly, on the tenets of feminist ethics.

Erez (2002), in discussing domestic violence and the criminal justice system, reiterates the fact that women, not men, are the primary victims of domestic violence; that is, the man's need to control and dominate underlies the violence, resulting in the oppression of women. She then places the violence within an historical perspective where, until the 1970s, the criminal justice system did not believe that battering of a female spouse was a crime, thus police did not view it as a serious offense but rather a private matter. However, since the 1970s, Erez notes that the women's movement, along with other societal forces that resulted in advocacy groups for crime victims, has been responsible for changes in attitudes and approaches to domestic violence. These changes made domestic violence not only a public matter but also a crime involving both the police and the criminal justice system and leading to arrest of the batterer. However, according to feminist scholars, arrest also has its problems, for example, ignoring the autonomy of women regarding the arrest and not providing them with the necessary resources to extricate themselves from their situations.

In matters of public concern and public health, nurses play an important role. A feminist perspective on domestic violence as a serious public health problem should expand the nurse's thinking about the role of feminist ethics in health care. But why are feminist ethics so important to nurses? Because some female nurses, like other women, have been socialized to think like men regarding ethics. This means that they often do not "see" the social-political environments that oppress women, particularly if they do not view themselves as being oppressed (which may or may not be so). In addition, the word feminist causes discomfort to many nurses, and they do not want to be labeled as one. Yet, they agree that women should not be oppressed and that nurses play an important role in enhancing the social and political environments to obtain better health care for women. Thus, nurses need to understand that, given the preceding beliefs, that they are in fact thinking about and practicing feminist ethics.

Principle of Nonmaleficence

The authors of all five articles in Volume 7, Number 1 of OJIN clearly communicate that domestic violence harms women. Some of the authors also address how domestic violence harms fetuses, children, elders, and men. Since nonmaleficence is at the ethical core of most societies and health care professions, it warrants our attention. According to Beauchamp and Childress (2001), "The principle of nonmaleficence asserts an obligation not to inflict harm on others" (p.113). It is usually translated as, "First, do no harm." This principle is supported by specific rules such as:

1. Do not kill.
2. Do not cause pain or suffering.
3. Do not incapacitate.
4. Do not cause offense.
5. Do not deprive others of the goods of life.

(Beauchamp & Childress, 2001, p. 117)

Keep in mind, however, that the principle of nonmaleficence and its supporting rules are prima facie, that is, they are always binding unless they conflict with equal or stronger duties that override them. Nevertheless, when reflecting on the principle and its supporting rules, one cannot escape their relationship to domestic violence: The principle and often all five of its supporting rules are violated.

We now examine some of the harms to health caused by domestic violence. Draucker (2002), citing the works of Campbell (1998) and Warshaw (1998), reports physical violence, including such injuries as lacerations, contusions, broken bones, and hearing/vision loss; sexual violence, including such problems as urinary tract infections, sexually-transmitted diseases, and sexual dysfunction; stress-related violence, including such problems as eating disorders, chronic irritable bowel syndrome, and persistent headaches; and psychological violence, including such problems as post traumatic stress disorder, depression, and substance abuse. Walton-Moss and Campbell (2002) concur with Draucker (2002) on the health consequences of domestic violence.

Griffin and Koss (2002) add to the above picture. In addition to physical, sexual, and psychological violence, they add economic abuse and stalking. By economic abuse they mean such tactics as limiting access to bank accounts, transportation, and educational opportunities in order to control the victim. By stalking they mean such behaviors as repeated threats occurring at the victim's home or office and delivered in person or by telephone or written messages. Griffin and Koss (2002) also identify five barriers that keep women from reporting partner violence: fear, cultural differences, dependence on the abuser, feelings of failure, and promise of change by the abuser.

Erez (2002) differentiates between domestic violence that is defined as criminal versus noncriminal. Stalking, for example, is considered a crime, whereas psychological and financial abuses are not. Here is an example, then, where law, the minimum standard, and ethics, the highest standard, depart. The principle of nonmaleficence and its supporting rules would clearly consider psychological and financial abuses as ethically wrong even though the law is largely silent on them.

Finally, Campbell, Sharps, Gary, Campbell, and Lopez (2002) discuss health consequences of domestic violence in African American women. They point out that the African American woman's experience is different than the Caucasian woman's experience. First, the problem of racism may cause African American women to refrain from seeking help for domestic violence; they feel the care they receive is inferior to that of Caucasian women. Second, in a study conducted by the above authors (Campbell et al. 2002), intimate partner femicide was most likely to occur if the man was unemployed and African American.

The previous five articles paint a devastating picture of the violation of nonmaleficence and its supporting rules. All rules were violated. Women were killed, caused pain or suffering, incapacitated, offended, and deprived of the goods of life (Beauchamp & Childress, 2001, p. 117). You ask, "How could all these tragedies occur in a so-called '˜developed country'?" "What can nurses do about it?" To address these questions, we now turn to two codes of ethics: The ICN Code of Ethics for Nurses, adopted in 2000 by the International Council of Nurses, referred to hereafter as ICN Code of Ethics; and the Code of Ethics for Nurses with Interpretive Statements, adopted in 2001 by the American Nurses Association, referred to hereafter as the ANA Code of Ethics.

Codes of Ethics for Nurses

The International Council of Nurses (2001) states "For too long violence has been seen as outside the domain of the health sector" (p. 29). However, nurses can take guidance from their codes of ethics about their obligations to battle violence. By examining the goals and interpretive statements of the ANA Code of Ethics and by examining the preamble and the elements of the code in the ICN Code of Ethics, nurses can identify some actions nurses can take to help victims of domestic violence, as well as gain some insights into the problem.

First, nurses have an ethical duty to respect the dignity and human rights of other persons and to treat them with compassion regardless of health condition, ethnicity, or life style. Duty is not a word to be taken lightly. A duty must always be carried out unless it conflicts with an equal or higher duty. Thus, in working with victims of domestic violence, no matter how difficult or unseemly, both codes clearly state the nurse respects "the inherent worth, dignity, and human rights of every individual" (ANA, 2001, p. 7) and " '¦human rights, including the right to life, to dignity and to be treated with respect (ICN, 2000, p. 2).

The lack of respect for human dignity and human rights is a core problem related to domestic violence. A person cannot bring him/herself to harm another person if the other person is genuinely viewed as possessing intrinsic worth. Those persons who inflict domestic violence possess character traits and values that dehumanize and oppress their victims. Likewise, individuals in many countries have certain rights, the most basic ones include the right to life and the right to safety, especially in their own homes. But domestic violence kills; its victims are mostly oppressed women. Domestic violence also robs the victims of their right to safety. The home becomes a battlefield where the victim does not know when the next battering will occur and what form it will take, whether physical, psychological, sexual, or economic.

Second, the ethical codes lay out that in terms of rendering nursing care to victims of domestic violence, nurses cannot withdraw from this situation because it is difficult or ugly. A significant part of that nonnegotiable ethical standard is that "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (ANA, 2001, p. 12). The ICN Code of Ethics for Nurses (2000) states, "Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering" (p. 2). If anyone within the health care system or outside of it tries to dissuade the nurse from using his/her advocacy role (unless the nurse's life is endangered or the nurse exceeds the boundaries of nursing practice), the nurse is protected by ethical codes.

Third, both codes call for activism by nurses. The ANA Code of Ethics calls for nurses to collaborate with the public and health professionals to promote the health needs of people, wherever they may be. In a like manner, the ICN Code of Ethics calls for nurses to collaborate with their national associations in applying ethical standards. This activism thus extends the nurse's role to legislative efforts and political action that can bring about social reform that addresses such issues as poverty, unsafe living conditions, homelessness, abuse, and violence. This context of violence was discussed in the Campbell et al. (2002) article on domestic violence and African American women. The interplay of the cycles of poverty, alcohol and other drug abuse, unemployment, racism, and lack of adequate education and health care all create a context within which domestic violence is high. The nurse can no longer ignore social issues at home or abroad. Ethical codes demand social action.

In summary, three links between domestic violence and ethics were made. The links focused on feminist ethics, nonmaleficence, and codes of ethics for nurses with examples taken from the ANA Code of Ethics and the ICN Code of Ethics. All three links contribute to nurses' understanding of the devastation of domestic violence and what they can do about it. The ethical codes mandate we do something about it not only at the individual and at the professional level but also locally, nationally, and internationally.

Domestic violence, wherever it occurs, diminishes every human being. The challenge is what nurses can do about it. Ask a woman if she is fearful of harm. Write a letter or speak to a legislator about domestic violence. Volunteer your skills at a shelter for victims of domestic violence. Open a discussion with a person from another culture about domestic violence. The answer is to move beyond ethical beliefs to ethical action.