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Create a weekly Ethics Log in which you record your thoughts in.
Record, in your Ethics Log, your response to the following:
• Reflect on an international health issue that has appeared in the media recently. Could this issue have been prevented? Why or why not?
• Does U.S. health care policy answer the needs of the health issue better than international policies? Why or why not?
Global Consciousness in the Twenty-First Century
Written in collaboration with Barbara Kupchak
What we remember, we can change; what we forget we always are.
After completing this chapter, the reader should be able to:
1. Discuss the relationship between Earth health and human health.
2. Describe the role and ethical responsibility of nursing in addressing local, national,
and global environmental issues.
3. Discuss nursing role, responsibility, and ethical stance in responding to local,
national, and global issues such as disaster, displaced persons, war and violence,
epidemics, and toxic chemicals and other pollutants.
4. Discuss historical events and patterns of health care delivery that have helped to
shape Western systems of health care delivery in the United States.
5. Describe trends and challenges of accessibility and financing facing health care
delivery systems around the globe.
6. Discuss factors prompting a renewed interest in traditional healing systems
7. Briefly describe factors affecting health care delivery for rural and urban aggregates.
There are many global concerns that have a significant impact on health and well-being
of people and the planet. Ethical and other issues associated with these concerns call for
both personal and professional responses from nurses at local, national, and international
levels. Examples of these issues include Earth health, natural and other disasters,
displaced persons, famine and malnutrition, child labor, use of torture, war and violence,
genocide, unexploded bombs and land mines, pollution, global warming, epidemics and
drug resistant organisms, bioterrorism, and access to and financing of health care (both
modern and traditional systems). Nurses need to be aware of both overt and covert
human rights violations that are at the heart of, or result from, many of these global
concerns. Discussion of nursing role, responsibility, and ethical considerations for several
of these concerns is included in this chapter. Students are encouraged to explore and
discuss appropriate nursing role and response related to global health issues not
Earth Ethics and Health
Discussions of ethics, especially health care ethics, generally refer to principles and practices
related to human experiences, values, and ways of being in the world. Rarely is there any
consideration of ethical treatment of the other-than-human world, indeed the Earth as a whole, the
health of which is so intricately connected to human health. Our sense of relationship with the
natural world is based in our worldview or cosmology. The Western scientific perspective flows from
a worldview that holds that there is a radical distinction between humans as subjects and the
natural world as object (Berry, 1999; Swimme & Berry, 1994; Uhl, 2004). This sense of human
experience being separate from and in opposition to nature has engendered and permitted a
destructive attitude toward Earth, and supported the belief that all species and resources of the
Earth have been put here primarily for human use. One significant assumption of the Western
worldview (that is now spreading globally) is that the more we try to control and “fix” nature, the
more we are doing what is right and good. This idea is based in a view (that began emerging in the
seventeenth century) of Earth and all her inhabitants (including the human body) as a complex
machine with ordered, predictable laws. This shift from an organic understanding of reality where
everything is alive, to a mechanistic view of reality, engendered the belief that humans have a right
to do anything they want with nature. Such an attitude results in little sense of ethical responsibility
toward the other-than-human world. To the contrary, it has allowed us to turn a blind eye to our
complicity in the exploitation of the planet. After several hundred years of demoting the natural
world to a collection of material objects available for exploitation, we are now realizing that the
complete disregard for the realities of ecological systems and the limited capacity of the natural
world to sustain such exploitation and destruction are contributing to the ill health of humans and to
the planet itself.
When we destroy the source of our life and sustenance, our health (physical, mental, emotional,
and spiritual) suffers. Indigenous peoples continue to teach what many people in the West are only
now beginning to remember, that all things are connected, that we belong to a whole universe, not
just to a city, culture, or nation. They also remind us that, as part of the interconnected web of life,
what we do to the Earth we do to ourselves. Indigenous peoples, mystics of many traditions, and
contemporary scholars understand the world to be a seamless garment in which there is no
separation between humans and nature, the sacred and the secular. They also recognize that we
cannot have healthy minds or communities without healthy land and environment (Nelson, 2004).
Understanding that we are all one single, sacred, Earth community, we need to recognize the
interdependence and unity of all in the natural world, and appreciate that all species have an
intrinsic right to exist. We need to move beyond a human-centered focus, begin to relate to the
Earth community as having core value in itself, and incorporate Earth ethics into our nursing ethics.
When we understand that, as humans, we are only one part of the interconnected Earth community,
we recognize that our ethical principles must address the integrity and health of the entire
community of life, and we understand the moral imperative to apply principles of beneficence,
nonmaleficence, and justice to our treatment of the whole Earth community. This in no way
diminishes human rights, rather it augments human well-being by fostering the rights of humans to
live within healthy ecosystems and receive the life-supporting benefits of the diversity, community,
and beauty of the natural world.
Earth health is a critical global issue because, as noted above, we cannot be healthy if the Earth
is not healthy. The manipulation of nature through scientific and technological exploration has
brought many benefits to human health, life, and general well-being. These benefits, however, have
come with a high price—a disruption of the life systems of Earth, violence toward and degradation
of much of the natural world, and disruption of both the human and bioregional communities. These
disruptions have led to poisoning of the air we breathe, the water we drink, and the soil and seas
that provide us food. Examples of health problems or potential problems related to disruptions of
the natural balance in nature include asthma; birth defects; autism; deformed frogs; trees dying
from acid rain; toxins in air, water, soil, and human tissues (including breast milk); drug-resistant
organisms; and malnutrition. Recognizing that some health care practices and products can harm
both humans and the environment (during manufacture, use, or disposal), nurses are taking a
leadership role in issues of environmental health (Nightingale Institute for Health and the
Environment, 2002; Sattler & Lipscomb, 2003).
Environmentally responsible health care requires awareness and action at many levels. One
level is seeking to move beyond the symptoms of an illness to address the source of the health
concern. This may need to be done on an individual, community, or global level. The impact of
smoking and second-hand smoke on asthma and pregnancy outcomes is one example of linking an
environmental pollutant to a health concern and taking action to decrease the pollutant. Many
health problems are related to toxic chemicals and other pollutants in the environment. These
pollutants come from many sources such as industrial production, everyday use in homes, heath
care and other institutions, manufacturing, agribusiness, waste disposal, and military actions. We
take these chemicals into our bodies through the food we eat, the water we drink, the air we
breathe, and through our skin. It is alarming to realize the impact of these toxins on human health;
for example, human breast milk has become one of the most toxic of foods (Lerner, 2004; Uhl,
2004)! Addressing the source of these toxins requires action on the personal level (such as
responsible use and recycling of plastic), the professional or local level (such as reducing the use of
and providing for the responsible disposition of disposable plastic equipment in the hospital), and at
the global level (such as working for legislation that mandates industry to provide a process for
recycling components of disposable products that they manufacture in a way that does not create
Nurses need to continue to be proactive in addressing the impact of the health care system on
the health of the environment. This includes considerations such as attention to the health impact of
chemicals found in products used in health care institutions, how the institution disposes of toxic
and other waste, the proper disposal of unused or outdated medications, the impact of antibiotics,
hormones, and chemotherapy that get into water and soil through human waste, and unnecessary
water and electric consumption. Nurses can take leadership roles in instituting recycling programs,
helping to develop institutional policies aimed at using energy efficient, recycled, and
environmentally friendly products wherever possible, and the like. The precautionary principle
provides a useful guide for ethically addressing the potential risk or harm to human health or the
environment of new products, processes, interventions, or technologies. This principle states “when
an activity raises threats of harm to human health or the environment, precautionary measures
should be taken even if some cause and effect relationships are not fully established scientifically”
(Raffensperger, 2004, p. 44). The precautionary approach affirms that when there is reasonable
suspicion of harm and scientific uncertainty regarding cause and effect, people have a duty to take
action to prevent harm. With this approach, the developer or proponent of a product must provide
sufficient information about and reasonable assurances of its safety before it can be marketed.
(Currently the burden of proof of the harmfulness of a product lies with the public or government,
generally after the product is already in use.) The precautionary approach suggests action steps
that include setting goals, examining all reasonable alternatives for achieving the goal and choosing
the least harmful way, monitoring results, heeding early warnings, making mid-course corrections
as needed, and assuring that all decisions include the affected parties and be open, informed, and
democratic (Montague, 2005; Raffensperger, 2004). The ultimate goal of the precautionary
approach is to determine how little harm is possible with a new product or development.
The Earth Charter and Nursing
The Earth Charter (http://www.earthcharter.org) can provide guidance to nurses and others for
promoting ethically responsible relationships with Earth and the global community. This charter is a
people’s treaty resulting from a decade long, worldwide, cross-cultural conversation about shared
vision and goals for global interdependence and shared responsibility for the well-being of the
human family and the larger living world. As a declaration of fundamental principles for building a
just, peaceful, and sustainable global society, the Earth Charter recognizes that issues of human
rights, environmental protection, equitable human development, and a culture of peace are
interdependent and indivisible. This Charter provides a framework and ethical vision for addressing
these issues. The following is a summary of the principles set forth in the Earth Charter:
Respect and care for the community of life, which includes
Respecting Earth and life in all its diversity
Caring for the community of life with understanding, compassion, and love
Building democratic societies that are just, participatory, sustainable, and peaceful
Securing Earth’s bounty and beauty for present and future generations
Ecological integrity, which includes
Protecting and restoring the integrity of Earth’s ecological systems with special concern for
biological diversity and the natural processes that sustain life
Preventing harm as the best method of environmental protection and, when knowledge is
limited, apply a precautionary approach
Adopting patterns of production, consumption, and reproduction that safeguard Earth’s
regenerative capacities, human rights, and community well-being
Advancing the study of ecological sustainability and promoting open exchange and wide
application of the knowledge acquired
Social and economic justice, which includes
Eradicating poverty as an ethical, social, and environmental imperative
Ensuring that economic activities and institutions at all levels promote human development in
an equitable and sustainable manner
Affirming gender equality and equity as prerequisites to sustainable development and ensuring
universal access to education, health care, and economic opportunity
Upholding the right of all, without discrimination, to a natural and social environment
supportive of human dignity, bodily health, and spiritual well-being, with special attention to the
rights of indigenous peoples and minorities
Democracy, nonviolence, and peace, which includes
Strengthening democratic institutions at all levels and providing transparency and
accountability in governance, inclusive participation in decision making, and access to justice
Integrating into formal education and life-long learning the knowledge, values, and skills
needed for a sustainable way of life
Treating all living beings with respect and consideration
Promoting a culture of tolerance, nonviolence, and peace
Ask Yourself: What Is an Ethic of Care for the Earth?
What does your culture teach about relationship with Earth and the other-thanhuman
part of a global community of life?
How do you see principles of beneficence, nonmaleficence, and justice reflected in
the Earth Charter?
What can you do, personally and professionally, to promote environmentally
conscious practices in your local area and health care setting?
What do you see as the role of nursing in developing and promoting an ethic of care
for the Earth?
Disaster—Nursing Response and Ethical Considerations
Throughout the world nurses play an important role in providing emergency care and in meeting the
on-going humanitarian needs of people affected by disasters. Disasters are generally described as
sudden events of massive proportion that result in large numbers of victims, displacement of
people, material damage, disruption to society, or a combination of these (World Medical
Association [WMA], 1994). Disastrous situations around the world may be linked to sudden events
and require long term as well as immediate interventions include drought, famine, and epidemics
(such as HIV/AIDS). Disasters may be termed natural (such as hurricanes or tsunamis),
technological (such as major chemical leaks), or accidental (such as a ship capsizing). The
proportion of the disaster may be due to a combination of these factors. For example, Hurricane
Katrina might well be termed a natural disaster; however, the weakness of the levy system that
contributed to the major flooding of New Orleans was a technological disaster. Another example is
human alteration of the land through activities such as massive logging and deforestation that
contributes to the severity of some flood related disasters. Scientists see a link between the
increase in the number and severity of natural disasters over recent years and climate change,
which is occurring in great part through human activity (Uhl, 2004).
Emergency and continuous health care are essential parts of any disaster response. Disasters,
from the health professional’s view, are situations in which there is an often sudden, unforeseen,
imbalance between the needs of people whose health and well-being are threatened, and the
resources and capacity of the health care system to meet these needs (WMA, 1994). Many health
related problems arise in a disaster. Disasters require prompt action, yet responders must often
deal with inadequate supplies and resources, and the need to get to victims who are in places that
may present health risks, be dangerous, or difficult to reach. The World Medical Association offers
guides for ethical practice for physicians in a disaster situation that are summarized below. These
apply as well to nurses. In the emergency phase, prioritizing treatment and management, or triage,
is the first ethical consideration. Triage must be done quickly and by an experienced person (often
a nurse) who is aware of available resources. Based on medical needs and intervention
capabilities, victims are separated into groups of those who can be saved and those whose
condition exceeds the available therapeutic resources. Those who can be saved are separated into
groups of those whose lives are in immediate danger and require urgent attention, those who are
not in immediate danger and who need urgent but not immediate attention, those needing only
minor treatment, and those with primarily psychological trauma. Because of the nature of trauma,
regular reassessment of victims in each group must be done. Perhaps the most difficult ethical
consideration of triage is the sense of abandoning a person whose injuries or care needs are
beyond the available care. In the aftermath of hurricanes Katrina and Rita a number of nurses
reported having to make very difficult decisions about which patients to save when electricity,
medications, and other needed supplies and equipment were no longer available. The ethical
stance in these situations is to save the greatest number of persons who have a chance of
recovery, restrict morbidity to a minimum, and do as much as possible to show compassion and
respect for those who are dying.
Ethical care of victims in disaster requires nurses to provide impartial assistance to every victim
without waiting to be asked, incorporating emotional as well as technical care. Nurses need to
obtain a person’s consent and address cultural differences as often as possible. Triage decisions
should be based solely on a person’s emergency status and not on any non-medical criteria.
Nurses need to respect cultural customs, religious practices, and other traditions, especially those
associated with dying, mourning, emotional and psychological response and needs. Other
considerations are to assure confidentiality as much as possible, particularly when dealing with
media and other third parties, and to be objective and respectful of the emotional and political
climate associated with the disaster.
Nurses need to be aware of and prepared to intervene with health needs beyond the emergency
response to a disaster. Principles of humanitarian action basic to this care include meeting critical
human needs and restoring personal dignity. Critical human needs that may become serious
problems during and following a disaster include nutrition (availability, quality, and special needs of
children), economic security, environmental health (water, sewage, air quality, and vector control),
communicable disease control, emotional and mental health (including attention to rape and other
forms of violence), basic health care (both preventive and curative), family and social support.
Disaster preparedness is becoming a very important set of skills for nurses worldwide. Students are
encouraged to explore the resources related to disaster preparedness at the websites of the
International Council of Nurses (ICN)—http://www.icn.ch/disas_relatedpubs.htm, and of the
International Committee of the Red Cross (ICRC)—http://icrc.org.
Displaced Persons and Victims of Armed Conflict
In the past decades disasters, wars, political instability, and armed conflict have forced growing
numbers of people worldwide to become refugees or displaced persons. Refugees are persons
who have fled their countries and who cannot or do not want to return due to well-founded fears of
death or persecution because of their religion, race, political opinion, nationality, or membership in a
particular social or ethnic group. Internally displaced persons are those who, because of war,
persecution, or other threats, have been forced to leave their homes, but who have not crossed an
internationally recognized border (International Council of Nurses (ICN), 2006). Victims of major
disasters and those in areas of famine or severe economic upheaval can become displaced
persons either temporarily or long term. Displaced persons often have serious health and social
problems related to deprivation (including basic human rights), physical hardship, stress, poor
nutrition, and generally poor health status. Displacement often separates family members, cuts
people off from community support, employment, educational opportunities, and cultural ties.
Refugee settlements are often overcrowded and may lack sufficient resources, including food and
sanitation, to meet basic necessities and health care needs. The majority of displaced persons
around the world are women and children. The conditions in refugee settlements engender
emotional cruelty and gender specific violence such as rape, sexual abuse and harassment,
spousal battering, and forced prostitution, and may also give rise to political unrest, particularly
when internment in such camps becomes long term.
Although international humanitarian law provides for protection of civilians in the time of war,
large humanitarian groups such as the ICRC and United Nations organizations must have the
permission of the ruling power in order to work in a country. Humanitarian aid often is unavailable to
internally displaced persons, who may also be victims of repressive governments. These people
may be left without basic necessities to suffer and die because the ruling government persecutes
the group in various ways, provides no assistance, and denies permission for outside aid. The
current situation and resulting genocide in Sudan is an example of such treatment of internally
Nursing involvement with refugees and displaced persons can occur at levels of emergency
needs, care and maintenance, and seeking ongoing solutions. The ICN (2006) suggests a number
of action areas for nursing involvement with issues of displaced persons. These include raising
public awareness and lobbying governments regarding the situation, identifying nursing and health
needs of displaced persons and mobilizing resources to address these needs, assisting with
emergency and resettlement programs, planning for provision and evaluation of health services
provided for displaced persons, implementing educational programs for nursing personnel, and
assisting nurse refugees. Recognizing that we live in a global community, principles of beneficence,
justice, and respect for human dignity compel nurses to advocate for those who are suffering both
close to home and globally.
Think About It: Nursing Response to the Plight of Displaced Persons
Baroness Cox of Queensbury (Interview, 2003), former co-editor of the International
Journal of Nursing Studies, is actively involved in international humanitarian work. She
calls for nurses to address ethical, legal, and professional implications of the plight of
displaced persons worldwide through the following questions.
If nursing is concerned for all humanity, why are we silent when vast numbers of
people are left to suffer and die unaided?
Should nursing not be raising the issue of denial of access to those suffering under
Where is the nursing profession’s voice urging governments to press repressive
regimes to allow humanitarian and human rights organizations access to groups in
need in their countries?
How can nurses use professional conferences, journals, and media to try to find
professional, legal, and ethical solutions to these problems?
If nurses, who have a professional mandate to advocate for those who are suffering,
remain silent, who else will speak? (p. 445)
How would you respond to Baroness Cox? How would principles of beneficence, justice,
and respect for human dignity guide your response?
How do her suggestions compare with recommendations of the ICN?
What action steps are needed individually and as a profession to address these issues?
War and Violence
We live in a troubled world, perhaps made more so by ease of global travel and instant electronic
communication. Conflict, violence in many forms, and war touch our lives in many ways, either
directly if we live in an area experiencing the violence, or indirectly through the media or the
presence of family or friends in war-torn areas. We cannot escape the impact of war and violence
on our lives, nor can we escape the need, as nurses, for an appropriate ethical response to these
realities. Inherent in national and international codes of nursing is respect for life and dignity of
people, and adherence to principles of beneficence, nonmaleficence, and justice. In the face of
modern warfare and increasing acts of violence worldwide (including torture and terrorism), we
need to ask ourselves what the ethical stance of nursing needs to be.
As noted in earlier chapters, the principle of beneficence directs nurses to do good and prevent
or remove harm. This includes defending and protecting another’s rights, seeking ways to keep
people out of harm’s way, and intervening to assist if the person is in danger. Nonmaleficence
directs nurses to do no harm, which includes the directives not to inflict suffering or to kill another.
Justice refers to fair and equitable treatment of individuals regardless of their backgrounds. Fair,
equitable, and appropriate distribution of resources in society is termed distributive justice.
Applying these ethical principles to issues of war and violence raises many ethical considerations,
which are discussed briefly here. Students are urged to pursue further reflection and discussion
about these critical global issues.
Precepts of doing good, avoiding harm, and preventing or removing harm impels nurses to
understand the effects of war and violence in order to know what and where the needs are and how
to intervene. One tragic effect of modern warfare is that frequently civilian casualties (especially
women and children) are more extensive than those of the soldiers (Tschudin & Schmitz, 2003).
Even after a war is over, unexploded land mines and bombs left in the region continue to create
casualties. The devastating effects of war and violence affect individuals and society and include
physical, emotional, spiritual, and social components. Physical and emotional trauma sustained in
war is compounded by poverty, destruction of societal infrastructure (such as roads, sanitation, and
communication), spread of infectious diseases, sometimes in epidemic proportions, and strain on or
destruction of resources necessary to meet basic health care needs. Traumas that have become
common in armed conflict around the world such as rape, torture, and maiming, and the stress of
displacement and having to rely on charity for basic needs contribute to the increase of health
concerns such as hypertension and post traumatic stress disorder. Fear, depression, insomnia,
flashbacks, and nightmares are part of the often life-long psychological fallout of war and violence.
An example of this is a man who survived the Nazi Holocaust and moved to a small town in the
United States after World War II. He became a successful businessman and was well respected in
the community. He owned a nice house in a friendly and safe neighborhood, but rarely lived there
because he felt insecure there. He lived instead (until his death at age 82) in a small apartment,
with several locks on the door, above a store in the downtown area because of fear that someone
would come for him in the night.
Environmental degradation resulting from war and armed conflict includes soil and water
pollution, destruction of crops, trees, other vegetation and animal habitat, and general ecological
disturbances. This affects the ability of the land to support the needs of the people for even the
basic requirements of food and water. A country’s resources are strained and possibly depleted by
warfare, limiting its ability to provide for the basic needs of its people. The lack of care and the
physical and emotional traumas sustained during the war can cause the impact of war to affect a
person’s health throughout life. The cost of war includes not just the resources needed for the
military action, but also the impact on the lives and health of individuals and communities, and the
resources needed for cleaning up, rebuilding, and repairing the various levels of devastation
caused by the war.
Nurses have an ethical responsibility to work to prevent war and conflict and the consequences
of devastation that they cause. The response to war and violence must move beyond local and
national considerations and embrace a global consciousness. This response requires taking
leadership roles at the national and international levels “advocating the prevention of conflict,
developing and teaching nonviolent ways to resolve conflict, being aware of international issues of
professional concern, learning how to exercise the profession’s political voice, and making
politicians and governments aware of the devastation and misery caused by aggression and its
drain on national and international economic, ecological, humanitarian, and emotional resources”
(Tschudin & Schmitz, 2003, p. 358).
Understanding that world peace is a prerequisite for developing, fostering, and maintaining
health, the ICN (2003) affirms the ethical responsibility of nurses to eliminate threats to life and
health caused by weapons of war and conflict. The ICN calls on national nurses’ associations to
work toward elimination of these weapons and land mines and to work to prevent the
consequences of all types of weapons. Action steps that they pose for nurses individually and
collectively include educating the profession and the public about the social, economic, and
environmental consequences of weapons that cause large-scale devastation, collaborating with
human rights and health groups, disaster prevention agencies, the media, and other groups in
lobbying manufacturers and governments against the production, distribution, and use of these
weapons, developing strategies for taking action to reduce the threat of these weapons, and
actively participating in disaster preparedness and response planning.
Along with working to prevent and avert war and armed conflict, nurses need to deal with issues
related to the immediate experience of war and violence. This includes working to alleviate the
suffering of and providing equitable care for injured persons on all sides of the conflict, assuring, to
the best of our ability, that human rights and dignity are maintained for all in our care, and assuring
that our practice is aligned with the ethical standards of the profession. Considerations discussed in
the previous section on disasters apply as well in situations of war and armed violence. In times of
war, nurses and other health care professionals may be asked or directed to participate in
treatment of or practices related to patients or other persons that they consider ethically
questionable. In such circumstances, the ethical stance for nurses is to follow the professional
codes of ethics, seeking support and guidance from professional organizations and others as
necessary. Professional codes mandate that nurses provide ethical and equitable care with respect
for human dignity for all victims of war, including civilians, military, and even prisoners of war.
Ask Yourself: What Is My Personal Response to War and Armed Conflict?
Morally justify your responses to the following questions using ethical principles.
Have I personally or professionally spoken out against the global devastation
caused by war and armed conflict?
How many people must be injured, killed, or displaced, and where must the violence
occur in order for me to find my voice and take action?
Are war and its multi-level costs ever justified?
Who is most affected by war and armed conflict and its aftermath?
Who should pay for the cost of war?
(Adapted from Silva & Ludwick, 2003.)
Health Care Access and Financing
Addressing global health issues at their source requires an awareness of the interconnectedness of
the whole Earth community. The challenge to provide health care for people worldwide requires
increasing effort, creativity, and global consciousness. Many variables play a part in this challenge,
not the least of which is the health of the Earth itself. Other critical factors include economics,
culture, politics, epidemics, disasters (natural and technological), war and violence, national crisis,
and global travel. The problems are further compounded by the limited appreciation of what it
means to live in a global community, national versus private health insurance, methods of health
promotion contrasted with curative methods of treating illness, tenuous relationships between
modern medicine and traditional healing systems, and ignoring the health of the environment in all
health care policies and practices. These factors all affect the functioning of health systems and the
care they provide around the world (Ausubel, 2004; Berry, 1999; Bodeker, 2000).
The fundamental principles upon which the health care delivery system is based and the way it is
financed define the parameters within which nurses and other health care personnel function.
Issues of health care delivery and the effectiveness of the health care delivery system are concerns
worldwide. In the United States and most of the Western world, delivery of health care is much like
a runaway train of high technology with its proliferation of markets for new medications and
expensive treatments. Further, this system is challenged to provide for an ever-increasing global
population with decreasing resources, both natural and monetary. Basic to this global concern is the
state of the health of the planet itself, ever-increasing cost of health care and the issue of its
sustainability. Scientists are bringing our attention to the growing concerns of global warming, and
issues of clean air, water, and environmental toxins. Developed and developing countries recognize
that the current and future health care systems have at their foundation expensive technologies and
medication, many of which have to be imported from other regions of the globe.
Health care systems must address global changes and challenges if they are to survive in the
twenty-first century. Important questions arise about how best to meet the health care needs of
people worldwide. Can countries address the needs of their people without relying on expensive
medications and treatments? Can local, existing systems of health care be utilized to provide basic
health services to rural and urban poor communities? In developing countries, can traditional
methods and systems of health care be utilized to promote health and prevent disease, thus
reducing the burden on the system? Has modern Western health care practice been lax in
preserving and utilizing the traditional methods in favor of technology, and at what cost? What
ethical principles need to be considered when addressing issues of cost limits, access, rationing,
justice, need and medical necessity, and quality of care? In order to gain an understanding of some
of the major issues facing Western health care, it is useful to explore the history of various
contemporary health care systems and their financing, including traditional systems.
Ask Yourself: What Cultural Influences Affect Your Health Care Practices?
All persons have roots in beliefs and cultural heritage from their family of origin and place
What do you know about the health care practices of your cultural origins?
Have you or anyone you know ever utilized any healing modalities that are not part
of what would be deemed modern health care?
A Brief History of Health Care Delivery: The Euro-American
From the earliest civilizations there is evidence of some type of health care. The methods of health
care were often a mixture of religious, civil, and mythological belief that combined to keep away
disease, prevent wars, and ensure survival of populations in order to keep the group strong.
Traditional healing systems generally recognize the interconnection between human health and the
health of the Earth and incorporate this understanding into their healing practices. In every culture
there have been individuals designated to provide care to the sick. Some were formally trained as
nurses and physicians, while others seemed to have a natural gift for the art of healing. Asian and
Middle Eastern peoples, such as the Mesopotamians, Babylonians, Hebrews, Persians, Hindus,
and Chinese, have recorded some type of system for the delivery of health care. In all of these
cultures, religious or civil laws enforced systems of disease prevention in matters of hygiene and
diet, some of which were connected to the various religious practices of the ancient civilizations.
Early Eras of Health Care Delivery
Achterberg notes that “the Sumerians, and not the ancient Greeks and Romans, are the parents of
Western healing systems” (1990, p. 14). Archeological findings in the area of ancient Sumer, which
is located in the vicinity of modern Iraq, include numerous prescriptions and two tablets that are
considered to be the oldest medical text in existence (Achterberg, 1990). Sumerian knowledge of
healing and theories of disease were dispersed to other areas through trade with the Phoenicians,
Greeks, and Egyptians.
The ancient Greek civilization represents a major force in the systematic organization of
education, both in secular and scientific fields. The most well-known name in ancient Greek
medicine and health care is Hippocrates, known as the Father of Medicine. His approach of
separating medicine and health care from religion, magic, and myth was considered purely
scientific for his time. He diagnosed from observed symptoms, with emphasis on treating the whole
patient, and he promoted continuous bedside care. His method of systematic record keeping of the
patient’s appearance, vital signs, and general bodily functioning became a standard for health care.
Hippocrates approached medicine and health care from the highest ethical standard, believing
medicine to be the noblest of arts. In addition, he believed that the physician’s conduct should be of
the highest quality and above reproach. Hippocrates gave the health care system organized
writings of medical books that included detailed descriptive case histories, technical practices, and
reports of research on various disease treatments, including treatments that worked and those that
did not, in order to avoid repeating errors in care (Kelly, 1985).
As nations and populations expanded, knowledge was disseminated from culture to culture,
constantly redefining the approach to health care, research, and practice. Alexander the Great, who
conquered Greece in about 339 B.C.E., spread what he learned in Greece throughout the entire
known world. He established medical schools in Egypt that included clinics, laboratories, and
libraries. Physicians were supported by the government, and could devote their time to practice and
research. Gradually, through various wars and assimilation of culture, Greek medicine
supplemented or replaced practices throughout the known Western world.
The empire of Rome replaced methods of health care that were based on folklore and magic with
a knowledge base developed in Greece. Within this developing culture, medicine and health care
soon became a part of the necessary education of upper-class men, and women’s health issues
and childbearing practices regained importance. Midwives became key figures in the care of
women (Kelly, 1985). Important contributions to health care delivery from the Roman Empire
include public health sanitation and public health law. The Romans instituted city planning that
provided for development of sewage systems, aqueducts, and baths. In addition, they can be
credited for the development of hospitals with male and female attendants to care for the sick.
A new era in the care of the sick occurred after Christianity became the official religion of Rome.
The Christian attitude of care for persons, based on a strong belief in the sanctity of human life,
was derived from Hebrew tradition as well as the teachings of Christ. Bishops assigned individuals
to care for widows, orphans, the sick, and the poor. Hospitals to care for the sick and institutions to
care for the poor offered combinations of outpatient and welfare services. Monastic orders of monks
and nuns, who were generally better educated than the ordinary person, controlled the health care
institutions. Their writings documented the care given to the sick and techniques used, which
provide us with early records of diseases, practices, and research for cure and care (Bullough &
Changes from the Middle Ages to the Industrial Revolution
During the thirteenth and fourteenth centuries, the organization and founding of medical schools
and universities and the advent of book binding all worked to promote a better educated health care
provider. Nurses, who were not as fully established as physicians, functioned as attendants who
made beds and gave baths to the sick.
As noted in Chapter 1, amidst the religious revolution that had taken place against the church of
Rome (known as the Reformation) in the early sixteenth to seventeenth century, the disbanding of
convents and monasteries led to severe impediments in the care of the sick. During this time, some
progress was made in midwifery, medicine, and nursing. However, it was not until the midnineteenth
century and the Industrial Revolution, when the demand for intellectual freedom brought
about educational institutions for men, that the health care system as we know it began to emerge.
During the nineteenth century, Florence Nightingale’s leadership influenced not only nursing
education and nursing care, but the health care of the world (Bullough & Bullough, 1978; Dossey,
2000; Dossey, Selanders, Beck, & Atwell, 2005; McDonald, 1998; Nightingale, 1859/1992;
Selanders, 1998a, 1998b).
Ask Yourself: How Have Things Changed?
Consider the discussion of the early era of the health care delivery system and
identify problems in early civilization that might still be seen in today’s world.
Consider how Florence Nightingale’s profound influence on health care systems
worldwide continues to affect health care today. How can nurses continue this
legacy in the twenty-first century?
Nightingale is perhaps best known for crafting the standards of Western secular nursing
education and practice. Her leadership was also felt in the area of public policy and social reform.
She spearheaded improvements in British military medicine, and greatly influenced public health
reform in Great Britain and India. She promoted what we now call holistic health, recognizing the
role of body, mind, spirit, and the environment in health and healing. Appreciating the importance of
environmental factors in healing, Nightingale directed her nurses to assure that patients had clean
water, sanitation, clean air and good ventilation, and limited noise. She was a pioneer in using
evaluative statistics to monitor the various factors influencing health and the effectiveness of the
health care system.
Changes Influencing Development of Modern Health Care in the United States
Health services in the United States developed from health care models in European countries.
These systems share the products of medical innovations that took place from the late nineteenth
century to the time of World War I, a time when major nations were changing from agricultural to
industrial economies. Such innovations as the use of anesthesia in surgery and the recognition of
bacteria as a causative factor in many widespread diseases provided the impetus that led to the
development of the modern hospital as it exists today. The dissemination and incorporation of this
knowledge among the large number of practicing physicians took at least a generation to
accomplish. Consequently, the importance of the place of the modern hospital in society was not
felt until the late nineteenth century and into the early twentieth century. At the time of this
revolution of knowledge, physicians, who were the primary health care practitioners, engaged
primarily in a private, fee-for-service practice that included office and home visits.
Physicians and Hospitals
In the United States, hospitals were generally privately funded, while European nations had both
tax-supported charity hospitals and private hospitals for those patients who had the ability to pay for
their own health care (Anderson, 1963). The primary purpose for hospitals built in Europe was
ministry to the low-income or charity patient, while in the United States, hospitals that were built by
private funding were open to charity patients as well as private-pay patients.
The development of hospitals affected European physicians by creating a class of specialists
who operated in the general hospital and also had the option of treating private-pay patients. These
specialists often created their own cottage hospitals, where they could treat their private-pay
patients. All other physicians in that system were excluded from practicing in a hospital. In the
United States, on the other hand, practitioners sought out appointments to the hospital system in
order to be able to admit patients, while at the same time maintaining private offices in which to see
their patients. This began a new approach to the use of the hospital system, in which resources
were used more extravagantly and the system was more democratic in its care of patients than the
European system. The United States health care system became immersed in greater use of
technology, industrial and management skills, and scientific methods, creating by some estimates
the best health care system in the world, and the most expensive (Anderson, 1963).
As an outgrowth of the development of hospitals, a greater awareness of public health problems
arose. Prevention programs for the public, such as sanitation, environmental issues, control of
communicable diseases, and maternity and infant care developed. Curative programs, which were
generally hospital-based, were supported by private and public funding. Hospital clinics that
provided outpatient services became the primary site of health care for low-income and indigent
patients. During that period, physicians provided these outpatient services free of charge and, in
return, were able to participate in the hospital system, where the latest in knowledge and
technologies was being introduced. This information could then be applied to the care of large
numbers of both private and charity patients. Hospitals provided physicians an opportunity to
develop their skills and to provide service to the public, thus fulfilling the physician’s commitment to
the public interest (Anderson, 1963).
Twentieth and Twenty-First Century Changes and Challenges
The United States health care delivery system in the later nineteenth century was affected by
sources of funding (private or public), the ability of the patient to pay, and the type of control
exercised by independent practitioners, which now included physicians, pharmacists, and dentists.
The development of an industrialized society in the United States, the growth of the economy, and
the increased capability of a growing health care system produced a healthier and more aware
population. However, twentieth-century changes created new challenges for the health care
system. Figure 13-1 presents some of the significant events that have influenced health care in the
United States in the nineteenth and twentieth centuries.
Figure 13-1 Selected Significant Events in Health Care History—Nineteenth and Twentieth
1862 William Rathbone opened a nurse training school, the
Liverpool Royal Infirmary, in consultation with Florence
1869 The first Board of Health was established in Massachusetts.
1872 The American Public Health Association was established.
1886 The Visiting Nurse Society of Philadelphia was established.
1893 The Henry Street Settlement, under the direction of Lillian
Wald, was founded to provide health promotion, disease
prevention, case finding, and follow-up care. Out of this system
came the first school nurse, Lina Rogers, who was assigned to
the public school system.
1896 The Nurses Associated Alumnae of the United States was
established, later to become the American Nurses Association.
1901 The Army Nurse Corp was established by an act of Congress.
1903 North Carolina was the first state to legislate the licensing of
1910 The Flexner Report exposed abuses in medical education and
1916 The Pure Food and Drug Act was enacted.
1918 An influenza epidemic produced 500,000 deaths in the United
1918 The Chamberlain-Kahn Act established the Venereal Disease
Division of the United States Public Health Service.
1921 The Sheppard-Towner Act was passed, providing grants-in-aid
to enable states to create their own bureaus of Maternal and
1923 The Goldmark Report was published, entitled Nursing and
Nursing Education in the United States.
1925 Mary Breckinridge developed rural health care programs that
become the Frontier Nursing Service.
1935 The Social Security Act authorizeed grants to aid public health
1940 Sister Elizabeth Kenny brought her method for treating
poliomyelitis to the United States.
1946 The Hospital Survey and Construction Act, known as the Hill-
Burton Act, provided for matching funds for the building of
hospitals to state and local communities.
1948 The Brown Report, Nursing for the Future, was published by
Esther Lucille Brown, emphasizing higher education for nurses.
1948 Eli Ginzberg’s report, A Program for the Nursing Profession,
recommended two levels of nursing: professional and practical.
1956 The Health Amendments Act was passed to provide
traineeships for public health personnel. It gave nurses an
opportunity for advanced preparation for positions in teaching,
administration, and supervision.
1962 State nurses’ associations eliminated discriminatory
1965 The American Nurses Association published its “Position
1965 The Social Security Act was amended to provide funds for the
health care of the elderly (Medicare—Title XVIII) and the health
care of the medically indigent (Medicaid—Title XIX).
1972 Revision of the New York State Practice Act acknowledged
nursing as an autonomous profession.
1977 Nurse Practitioners providing rural health care authorized to
receive Medicare payment.
1978 Louise Brown, the first test tube baby, was born in England.
1981 AIDS was identified in the United States.
1982 Maryland was the first state to grant direct third-party
reimbursement for nurse practitioner services without physician
1983 A prospective payment system based on Diagnosis Related
Groups (DRGs) was created under Medicare.
1986 The National Institute of Nursing Research (NINR) was
established at the National Institutes of Health (NIH).
1989 The Omnibus Budget Reconciliation Act (OBRA ‘89) phased in
new Medicare payment scales for physicians. It mandated
direct Medicaid reimbursement for pediatric and family nurse
1990 The Patient Self-Determination Act and the Americans with
Disabilities Act were enacted.
1992 Congressional mandate created to establish the Office of
Alterantive Medicine at NIH.
1993 The Omnibus Budget Reconciliation Act (OBRA ‘93)
established an all-time record cut in Medicare funding and
contained the Comprehensive Childhood Immunization Act to
provide vaccines for Medicaid eligible and Native American
1994 President Clinton’s health reform proposal, the American
Health Security Act, failed.
1997 Medicare reimbursement for nurse practitioners and clinical
specialists authorized by federal legislation.
1998 The NIH Office of Alternative Medicine was elevated to status
of the National Center for Complementary and Alternative
Medicine, and was mandated to facilitate research on and
provide public information about alternative medical
1999 NINR becomes the lead institute dealing with palliative care
and end-of-life issues.
2000 Landmark legal decisions against tobacco companies related
to the health hazards of tobacco use.
2000 Needlestick Safety and Prevention Act signed into law.
2000 Several states included on their ballots health care reform
measures calling for universal health care.
In the early part of the twentieth century, a growing nation experienced population increases and
a greater influx of immigrants, with over one million immigrants from southern and eastern Europe
in 1905 alone. The need for health care and related services warranted attention. Medical schools
and nursing schools expanded to provide personnel to meet the demand. Science, technology,
public health services, and medicine progressed at an increased rate. Physicians and scientists
began to use such diagnostic tools as x-rays. They made strides toward reduction of infectious
organisms through the use of rubber gloves. They began to research the causes and cures of
diseases such as yellow fever and typhoid and to use radiation to treat breast cancer. Amid such
major advances as the discovery of penicillin, the proliferation of science and technology, the
advancement of the professions of nursing and medicine, and the changing conceptualization
about disease, a phenomenon unique to the United States emerged: the American hospital system.
This phenomenon has colored the health care system in the twentieth century and into the twentyfirst
century as well.
Ask Yourself: How Do Nineteenth-Century Concepts Affect Twenty-First-Century
What concepts or practices regarding health care from the late 1800s and early
1900s still affect a patient’s access to health care today?
How is the health care delivery system that we know different from the system at the
turn of the nineteenth century?
What is your vision for health care for the twenty-first century?
The later part of the nineteenth century and the first two decades of the twentieth century saw the
transformation of hospitals from asylums for the poor to modern institutions, dedicated to science
and improved patient care. Physicians expanded surgical interventions such as tonsillectomies,
removal of tumors, and many gynecological operations. Nurses began to take a more active role in
managing the hospital environment to control infection, and began to have more responsibility for
technical management of patient care through duties such as taking the patient’s pulse,
temperature, and blood pressure (Stevens, 1989). Patterns that developed in the health care
delivery system in the early part of the twentieth century can still be seen today. Physicians gained
a new and strong identity and prestige, and the American Medical Association (AMA) became a
powerful force. Physicians gained increased authority in the routine workings of hospital systems,
shifting the balance of power from boards of trustees to the medical decision makers (Stevens,
As a result of battlefield experiences in World War I, nurses, physicians, and other health care
workers designed and set up streamlined, technically proficient, and very efficient specialized
hospitals for the acutely ill or injured patient. On the home front, in response to ever-increasing
numbers of immigrants, models of health care with emphasis on prevention and community
interaction were developed. Prior to the war, the elite area of nursing was public health, with nurses
at the forefront of campaigns for infant care and welfare, tuberculosis, and infectious disease. The
war, however, emphasized the glamour of hospitals, and by 1920, more than half of the general
hospitals in this country had schools of nursing attached to them. Student nurses staffed hospitals
and were socialized into the hospital system. Like physicians, nurses became caught up in the
culture of the acute health care environment and were reluctant to expand their professional
interests into public health and the social aspect of health care (Stevens, 1989).
After World War I, the idea of group practices for physicians began to take hold, and the
movement for health insurance began to develop. With the encouragement of President Theodore
Roosevelt, workers’ compensation was the first form of social insurance to become prominent in
this country. Thirty-seven states passed laws that sanctioned workers’ compensation by 1919.
Through this movement, the cost of injury and damage to workers because of job-related hazards
was passed on to industry. The health insurance movement entered a fast track, supported by the
AMA and various physicians’ groups around the country. During this time, the struggle for access to
care and control of fees and services escalated (Stevens, 1989).
The 1920s were years of growth and expansion of the health care industry. Consumerism
flowered in direct relationship to the growth of the health care industry. As the public became aware
of the availability of modern techniques, they wanted the best available. The health care delivery
system developed into a middle-class entity in which many advances were taking place in private
care, while the poor were increasingly underserved. By the end of this decade, there was
increasing criticism of the cost and financing of the health care system, and the question of equal
care for all income levels was raised. The rich and middle class were accused of having the best
available to them, while the poor were viewed as manipulative of the very system that wanted to
provide charity care to them.
During the Great Depression, government and charity hospitals were overrun with patients
unable to afford health care, causing health care institutions to lose income and question their
survival. The various health care professions pulled together to care for the sick, and a renewed
sense of dedication kept a strained system afloat. Continually rising costs of health care led to
development of plans for health insurance for everyone in the 1930s. The original Blue Cross plans
were an outgrowth of the need for payment for continued growth of hospital and health care
technologies. Thus, a prepayment insurance plan was born, and the health care delivery system
grew by leaps and bounds. During the ensuing years, major federal grant programs such as the
Hill-Burton Act of 1946 funded the construction of health care facilities, and the science of medicine
expanded through laboratory and clinical research. World War II prompted advances in health
services that included therapy for prevention and treatment of shock, better blood replacement
techniques, and research on gamma globulin, steroids, and other drugs, all of which increased the
possibilities for successful treatment in surgery and internal medicine (Stevens, 1989). Expansion
in the health care industry continued in the postwar years.
Think About It: How Do World Events Affect Health Care Delivery?
In reviewing history it is evident that seemingly nonrelated events can steer the course of
other events, as has been noted in the development of the health care delivery system.
How have major world events of your lifetime affected the course of health care
Identify ethical issues that have arisen in association with these events.
Between the passing of the Hill-Burton Act in 1946 and the enactment of Medicare legislation in
1966, the United States health care delivery system hit a new wave of expansion. The most widely
known image of expansion in hospitals was the intensive care unit, with the greatest expansion
between 1950 and 1965. In the early 1960s, coronary care units began to flourish, and by the mid-
1960s premature nurseries, respiratory units, physical therapy units, and units dealing specifically
with postoperative surgeries and neurosurgery were functioning in every fully operational hospital.
Because of technological expansion, the cost of health care increased rapidly.
Expanding Health Insurance Coverage
Seeing a need and opportunity, the insurance industry began to compete with Blue Cross plans to
provide third-party coverage for health care. These insurance plans removed the anxiety related to
paying large hospital and health care bills, and also removed incentives from health care
institutions to keep their costs down. Hospitals passed down increased costs to insurance
companies, who in turn passed the cost on to the individual insurance subscriber. Because
individual citizens had insurance, they demanded more and better service, and the system drove
itself through the supply and demand cycle (Califano, 1986).
Medicare Parts A and B, which was passed in 1965 and enacted in 1966, essentially gave
hospitals and other health care institutions a license to spend, and bigger and better were the
watchwords. The health care delivery system was caught up in a whirlwind that has escalated to
the point where the system is facing the need for serious change and the possibility of rationing at
the beginning of the twenty-first century. Spiraling costs have prompted development of costcontainment
mechanisms such as Diagnostic Related Grouping, case management, and managed
care systems, which affect current health care delivery. Standardization and constraints of health
insurance plans are more and more defining the care that patients receive in the present health
care delivery system. Many people have no insurance for health care, and health care institutions
have reverted to the charity care that existed in the first part of the twentieth century. The recent
Medicare Part D drug benefit program, developed in response to the increasing cost of medications
for elderly on fixed incomes, has loopholes that limit its ability to meet the needs of many Medicare
recipients. The future of the system is uncertain, and continues to be influenced by political
structures, economic constraints, and worldwide societal needs and demands.
Global Needs and Finite Resources
Health care resources worldwide are limited and making choices regarding who receives these
resources is difficult at all levels of care. Although ethical principles direct us to distribute health
care resources justly and equitably, there are powerful local and global social, political, and
economic forces that urge both for and against the rationing of health care (Povar et al., 2004). In
developing countries, access to modern health care may be very limited for much of the population
because of limited governmental resources for health care, distance from facilities, and limited
ability to pay. Basic health care services that we take for granted in the West, such as
immunizations, antibiotics and other medications, and common surgical and other treatments are
unavailable or too expensive. Health care needs may be addressed by traditional healing practices,
local outreach workers who do their best with limited resources, periodic visits from health care
teams from the government or abroad, or not at all. Difficulty accessing health care is often
compounded by political unrest, economic instability, and social, cultural, and other factors that
contribute to a large gap between the rich and the poor. Ultimately a large portion of the population
in many of these countries suffers from poor health.
On the other hand, all industrialized nations, with the exception of the United States and South
Africa, have some form of universal health coverage that covers basic health care needs. However,
all of these programs are not equal and most function less smoothly than one would hope. These
systems vary in regard to the amount of government and private involvement in health care delivery
and contribution for health insurance. Some countries have a combination of several methods.
Germany, France, and Japan, for example, mandate benefits coverage, the cost of which is shared
by employers, employees, and government tax revenues. These health care delivery systems
share three traits with the system in the United States: Medical care is offered through private
physicians and through private and public hospitals; patients may choose their providers; and most
people in these countries have health insurance coverage through their place of employment.
Health insurance is offered to the citizens of these countries through multiple third party insurance
agencies. Similar problems to those in the United States exist, such as high costs and increased
spending for technology. However, every citizen has some type of health care coverage. In an
attempt to hold down rising health care spending, all have instituted direct controls on the price of
health care. Canada and Great Britain have developed national health care systems that provide
health care for their citizens. The government-run plans provide cradle-to-grave services that are
financed through taxes. These plans enable patients to receive free services, and to choose their
own hospitals and physicians. The plans pay salaries to physicians and operate their own hospitals.
There are both champions and critics of the national health insurance systems in Canada and
Britain. Some say the systems are sound, while others say they are flawed. In Canada, for
example, citizens can go to physicians or hospitals of their choice when they need care. Physicians
bill the province for patient care. Patients do not pay for services, nor are they required to fill out
endless forms. Negotiations for fees, cost-containment measures, and salaries take place between
the provinces and the health care system.
The national health insurance system in these countries have their critics. Some say the system
is flawed, and that being insured in this way sets up a system of rationing because of insufficient
funds for specialized health care. It has been said that waiting for care in these systems sometimes
means death. Access to certain procedures and technologies is limited. Waiting lists are getting
longer. Critics say that there is an unequal access to health care from province to province,
depending on the affluence of the province. Some Canadian citizens who can afford to pay out-ofpocket
come to the United States for specialized care and surgeries. In all instances, the increase
in health care spending due to the high cost of technologies and research is having an impact on
these systems in much the same ways as it is across the globe (Canadian Health Care, 2007;
Health Canada, 2007).
Information about national health care systems worldwide is available at
http://www.allianzworldwidecare.com/EN/Geninfo/nationalhealthcaresystems.php. Students are
encouraged to visit this website to compare and contrast what is offered by health care systems in
In the United States, the burden of dealing with issues of health care access, limited resources,
justice, rationing, and quality involves many players, including insurance companies, governmental
agencies, managed care organizations, individual clinicians, and patients. A workgroup convened
by the American College of Physicians and the Harvard Pilgrim Health Care Ethics Program
developed a statement of ethics of managed care (Povar et al., 2004). The interdisciplinary group
consisted of patients, nurses, physicians, social workers, medical ethicists, and managed care
representatives. The four principles set forth in this statement are summarized here.
1. Relationships are critical in the delivery of health services. They should be characterized
by respect, truthfulness, consistency, fairness, and compassion. This implies truthfulness
and openness among patients, clinicians, and health plan purchasers, maintaining accurate
and honest records, supporting the importance, intimacy, and ethical obligations of the patientclinician
relationship, and honesty on the part of patients regarding their health condition and
2. Health plan purchasers, clinicians, and the public share responsibility for the
appropriate stewardship for health care resources. This implies including all parties in
public dialogue to shape policies on access to and quality of care, and on resource allocation
decisions; recognizing that a clinician’s duty is to promote the good of patients, practice
effective and efficient care, use resources responsibly, and advocate as vigorously for
vulnerable and disadvantaged patients as for any other patient. Included in this principle is the
understanding that all involved parties (patients, clinicians, and insurers) are in discussion
about what health care needs can reasonably be met with available resources, that all parties
understand and honor the rules and coverage of their contracts, and that all commit to
effective, quality health care with consistency and fairness.
3. All parties should foster an ethical environment for the delivery of effective and efficient
quality health care. Implicit in this principle is the understanding that agreements between
clinicians, health plans, and health care organizations are congruent with professional ethical
standards, and that all parties share the ethical obligation to protect the confidentiality of patient
4. Patients should be well informed about care and treatment options and all financial and
benefit issues that affect the provision of care. This implies that patients receive sufficient
and appropriate information to support informed consent or refusal of treatment, that clinicians
disclose any potential conflict of interest to patients, and that purchasers and health plans
inform patients of any arrangements that may influence care.
These principles do not solve the socioeconomic and political problems contributing to the rising
cost and limited resources faced by the health care system. While nurses need to work to address
these issues individually and as a profession, they must continue to deal with the ethical and moral
dilemmas associated with these difficult issues in the changing health care environment. The
purpose of these principles is to provide some guidance for ethical practice in a health care system
where resources do not always meet the need, regardless of the setting.
Ask Yourself: Access to Health Care—Rights and Responsibilities
Much of the discussion regarding the health care delivery systems of the United States,
as well as those of many countries in the world, is a commentary on access to what is
termed modern medical care.
How does access to health care affect an individual’s participation in the health care
What is our individual responsibility in the big picture of these vast health care
Do you consider health care a basic right? If it is a right, what are our individual
responsibilities in ensuring this right for all citizens?
What ethical issues arise when access to care is limited for some people and
available to others?
Alternative Traditions of Health Care
Indigenous populations in cultures throughout the world have traditional forms of health care that
view humanity as connected to the wider dimensions of the Earth and nature. In developing
countries, these forms of traditional healing systems provide comprehensive approaches to
prevention of illness and promotion of health that go beyond the scope of modern medical care.
The World Health Organization (WHO) refers to these systems as holistic—that is, viewing a
person in totality within a vast ecological spectrum, and emphasizing the notion that illness or
disease occurs as a result of an imbalance between the person and his or her ecological systems
An important component of traditional systems of health care is their basis in models that take
into account mental, spiritual, physical, and ecological factors in assessing health and well being. A
basic concept of all traditional health care systems is that of balance between mind and body,
function and need, and individual, community, and environment. Illness or disease is thought to be
a breakdown in the balance in one or more of these areas. Treatments are designed to restore
health and balance between the individual and his or her internal and external environments. While
these models of traditional health care systems have been considered primitive and
unsophisticated by modern practitioners, an increasing number of developing countries are
showing a new interest in program development toward revitalizing these traditional systems. There
are several factors at work in promoting this resurgence of interest.
The majority of rural populations of developing countries cannot afford Western types of medical
health care. Rural people have to travel many days to reach the larger health care centers,
resulting in loss of wages in addition to money spent for travel and medicines. In Asia, the
traditional systems are being incorporated into other, more formal health care systems to provide
for care and ease the burden of cost. India has over 200,000 traditional practitioners. In Thailand,
the Ministry of Health promotes the use of traditional medicinal plants in primary health care, staterun
hospitals, and health service centers. In Korea, 20 percent of the national health care budget is
directed to traditional health care services. Health insurance coverage is available for Oriental
medical treatments and traditional health care methods (Bodeker, 2000).
In Africa, the governments are facing huge bills for the exploding AIDS crisis. These
governments are exploring their traditional indigenous medicinal treatments for inexpensive and
effective ways to relieve the suffering of AIDS patients. Health care providers in Uganda have been
active in promoting research into traditional medicine for treating people with AIDS.
China has had a policy of integrating traditional health care into the national health care policy for
over forty years. The Chinese are trying to combine the modern and the traditional as formal
components of health care provision. In China, the traditional health care providers perform the
majority of care to the poor and rural communities. The country physicians are educated in a threeyear
program that includes a combination of traditional medicine and modern medicine. Modern
Western medicine is being strongly pursued at great financial cost to the government, but at the
same time hospitals and health care systems offer a choice to patients. Persons who take
advantage of these choices are often the older and the less affluent. As the country is opening up
to capitalist beliefs and free enterprise, some Chinese citizens who now have the financial means
to make different choices are choosing Western methods of treatments, and often ignore the tried
and true Oriental methods for status reasons. The younger generation of Chinese seem to believe
that what is Western is always better. In observing some of the health care delivery in China, there
is evidence that the government, while allowing the practice of the ancient Oriental medicine, is
putting a strong emphasis on a belief that technology is the answer to health care in this heavily
populated country. This is especially disconcerting, in view of the fact that Oriental medicine and the
tradition of health care with alternative choices have been functioning well for two thousand years,
and Western health care providers are beginning to research and utilize these traditional systems of
care in order to offer them to their patients.
Ask Yourself: What Do You Know About Traditional Healing?
Traditional methods of healing and health care have kept indigenous populations healthy
and functioning for thousands of years. Many countries are trying to reinstate these
practices to promote health and reduce the cost of health care and health care delivery.
How do you think traditional and modern healing systems should relate to each
What traditional methods of health care are available in your community or nearby
With what traditional or folk health practices are you familiar? Have you or persons
you know utilized these practices?
Challenges for Rural and Urban Aggregates
Problems in the delivery of health care to populations around the world occur not only because of
expensive technology or lack of money to pay for insurance, but also because of geographic
barriers. Rural populations in the United States and abroad often have to do without services
because of lack of providers and facilities within a reasonable distance from their homes. Health
care for persons in these populations requires a day off of work for travel and waiting in crowded
waiting rooms. Many rural areas lack health care personnel, and emergency care is often
nonexistent. In one mid-Atlantic state, all counties boast of an access to a 911 emergency number,
but for some, the switchboard and EMT vehicle is three counties away and travel is over narrow
mountain roads. Patients often delay treatment or do not become involved with prevention or health
education plans because they require so much effort to accomplish. In addition, many rural citizens
tend to be older persons for whom travel and finances are a great consideration in health care
The urban poor face similar access problems, not because care is geographically distant, but
because access requires trips to places they cannot afford or free clinics, where lines are long and
workers are few. Individuals are often required to take time from work, like their rural counterparts,
in order to see a provider. Medications may be unaffordable. Large immigrant populations live in
overcrowded situations in the urban setting. In addition to financial constraints, there may be
language and cultural barriers and lack of knowledge about how to access the system.
Think About It: Health Care Changes and Challenges
The challenges and changes in health care can seem insurmountable and overwhelming.
It seems as though only the very wealthy will be able to have health care services. Some
sociologists say that the middle class is disappearing and that this country, as well as
other world countries, will have only the rich and the poor. Health care costs are rising,
and there seems to be no end to it.
How should these issues be addressed? How should nurses respond to these
What issues have you encountered in accessing health care providers for you and
Are you able to afford a comprehensive health plan? If not, what do you do when
you become ill?
Global conscious is needed to address twenty-first century health care needs and issues. Nurses
must be aware of and prepared to address the global concerns that have a significant impact on
health and well-being of people and the planet. Nurses need to apply principles of beneficence,
nonmaleficence, and justice to relationship with Earth as well as to humans. Recognizing that
human health depends on the health of Earth, nurses must engage in and promote environmentally
responsible health locally and internationally. Examples of these issues include natural and other
disasters, displaced persons, famine and malnutrition, child labor, use of torture, war and violence,
genocide, unexploded bombs and land mines, pollution, global warming, epidemics and drug
resistant organisms, bioterrorism, and access to and financing of health care.
Historical awareness enables us to have a more informed view of circumstances in the present.
Contemporary issues and concerns regarding health care delivery and financing are related to the
historical interplay of advances in scientific and medical knowledge, social and political climate, and
waxing and waning of economic and other resources. Current parameters in which health care
providers function are changing. Acute-care hospitals are changing the focus of, and in some cases
limiting, services, and many people are looking to the traditional healing systems of various cultures
to provide needed health care services. Although some countries ensure access to basic health
care services for their citizens, many individuals throughout the world have limited or no access to
basic health care. Questions regarding access to and availability of resources are not new, but they
must be addressed anew in light of the various currents within contemporary society. The future of
the system is uncertain, and we must consider whether issues of the past are destined to repeat
themselves. Perhaps we can take what is positive from the past, and blend this with both traditional
and modern healing approaches in order to rescue a flawed health care system in this country and
around the world.
Earth health and human health are intricately interconnected, and nurses need to include
ethical considerations of relationship with Earth into nursing practice. Twenty-first century
health care needs and issues require global consciousness. Nurses need to work individually
and collectively to both meet the needs of those affected by global issues such as war,
violence, disaster, famine, epidemics, and displaced persons, and work as well to prevent the
devastation they cause.
Systems of health care, which have existed to address societal needs for healing from early
civilization to the present, have been influenced by cultural, political, economic, religious, and
scientific factors throughout history.
Scientific and medical innovations, coinciding with the shift in Western nations from agricultural
to industrial economics in the latter nineteenth and early twentieth centuries, provided a basis
for modern day health care. Societal changes such as wars, women working more outside the
home, and the influx of immigrants have raised new issues and concerns for health care
delivery at various times in United States history.
Skyrocketing health care costs can be traced to the advent of health insurance (1930s and
later) and the enactment of Medicare and Medicaid (1960s), which removed incentives from
health care institutions and physicians to keep costs down, and to public awareness of the
availability of medical interventions, which prompted consumers to demand the best care and
services available. Difficult decisions emerge with issues of access, cost, and justice.
Expansion of hospital and other health care services has reached a point of crisis in which outof-
control health care costs have prompted imposition of external controls on institutions and
health care providers. Many people have no means of paying for expensive services.
Some nations provide basic health care services for their citizens, while people in many areas
suffer from limited access to or availability of such services. People in both developing and
industrialized countries are exploring ways to incorporate traditional and modern healing
practices into contemporary health care systems, in an effort to utilize the benefits of both
systems in meeting the health care needs of society.
Problems of access to and payment for health care services are of special concern among
rural populations and the urban poor.
Discussion Questions and Activities
1. Read the Earth Charter at http://www.earthcharter.org and compare the principles
it sets forth with those found in nursing codes and position statements such as
those found at http://www.nursingworld.org, http://www.cna-nurses.ca, and
http://www.icn.ch. How can the Earth Charter help us to integrate Earth ethics into
2. At the nursing websites noted above, explore, compare, and contrast position
statements and policies related to disaster preparedness, displaced persons, war,
violence, and other global health issues. Discuss with classmates.
3. Investigate disaster preparedness plans and policies in your town or city and
health care agency.
4. Interview or read a biography of a person who worked as a nurse during or within
the decade following World War II or the Vietnam War, and discuss nursing roles
and duties, types of health concerns for which patients were hospitalized, and
what were considered new therapies at the time. Compare the information you
obtain to your experience of health care today.
5. Review nursing and medical journals and texts from the earlier part of the
twentieth century regarding issues of concern in practice and to the profession.
Compare and contrast these issues to issues of current concern.
6. Imagine that it is the year 2040, and you are being interviewed by a nursing
student about factors that affected health care delivery and financing in your early
days in nursing. What would you say?
7. Discuss global issues related to health care delivery. Which of these issues would
have the greatest impact on your nursing practice and why? Use the Internet to
investigate health care issues in a non-industrialized country. Share with
classmates how these issues might affect your nursing practice.
8. Describe the impact of health delivery and financing on patient care and
outcomes. Identify potential ethical dilemmas related to current systems of delivery
9. How should traditional and modern healing practices and practitioners relate to
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