Project Abstracts
A Case for Triadic Trust: Nurses, Patients, and Institutions
In this paper, I show that in the context of nursing, trust isn't a property of the dyadic relationship between nurses and patients, but instead is a feature of nurse-patient-healthcare institution triads. Understanding trust as triadic in the healthcare context is important, I argue, because it emphasizes the pervasive role institutions have on breakdowns in trust between nurses and patients that is otherwise obscured. Nursing exhibits features of both interpersonal and institutional accounts of trust. Nursing demands trust in nurse-patient relationships. And yet, the care nurses provide is a form of labor, highly professionalized, systematized, and resourced by healthcare institutions. Healthcare institutions, such as hospitals, are vested in the experiences of both nurses, their largest workforce population, and patients, their primary consumer. They also play a critical role in shaping the social and physical environments in which patients receive care and nurses work. As such, healthcare institutions are a primary locus for cultivating normative expectations around trust within the nurse-patient relationship. However, the very healthcare institutions that create those normative expectations in the first place, also create conditions that promote trust-betrayal. Thus, healthcare institutions set up expectations for trust relationships between nurses and patients that are nearly impossible for nurses to fulfill. I call this the Dilemma of Professionalized Trust. This dilemma highlights a case of trust that is both interpersonal and institutional, and recharacterizes the nurse-patient relationship from a dyad to a triad, with institutions as a third party, one that intervenes on and shapes the nurse-patient relationship.
Shared Blame: the Preservation and Repair of Trust
In this paper, I show that blame can help restore trust when it is shared between clinicians and institutions in the context of medication errors. I utilize the case of RaDonda Vaught, a nurse criminally charged after accidentally administering a lethal dose of the wrong medication, to illustrate how blame can be shared such that it fulfills what I call its trust-reparative function: the restoration of trust across all participants in the clinician-patient-institution relationship. Shared blame demonstrates what the existing debate on clinician versus institutional responsibility and blame fails to adequately capture, that trust and blame in healthcare are features of networked relationships that both clinicians and institutions are responsible for facilitating between themselves and with the patient. Shared blame, as I characterize it, further makes salient three relational goods that result when both clinicians and institutions respond to errors by sharing blame: 1) acknowledgement that the error, and its consequences for the patient, occurred; 2) appropriate emotional regard for the harm of the error; and 3) the potential for sincere apology. Using Vaught’s case, I examine different social dynamics between clinicians and institutions that occur when blame is either unilaterally or disproportionately discharged between parties rather than appropriately shared. When clinicians and institutions engage in the ideal of sharing blame, it prevents the escalation of further conflict and further enables them to appropriately prioritize repair with the patient and family. Shared blame is necessary for all parties to maintain healthy trusting relationships in the face of imperfect healthcare administration.
A Time for Dirty Hands? Clinical Practice, Clinical Ethics, and the Law in 2025 (With Daniel Kim)
In this paper we argue that Walzer’s conception of dirty hands can help make sense of how clinicians and clinical ethics consultants can respond to the changing legal landscape under the Trump Administration. Good clinical practice and good clinical ethics recommendations are aided by a narrow gap between what ethical reasoning suggests is morally permissible and what the law finds legally acceptable. Under the current Administration the gap between these is expanding at a rapid pace, leading to uncertainty, anticipatory obedience, and a chilling effect among both clinicians and consultants. We suggest that as this gap expands it may be permissible for clinicians and consultants to embrace dirty hands in two possible ways: 1. Clinicians and consultants both can resist the law in their practices in the form of civil disobedience, and have dirty hands for breaking (or recommending to break) the law to continue providing the medical standard of care to patients, trading off on legal consequences for the benefit of practicing with integrity for their professional ethical commitments. 2. Clinicians and consultants can comply with the letter of the law in order to remain available to care for as many patients as they can to the extent possible prescribed by the law. This may entail the use of work-arounds where possible, and trading off on ethical values embedded in professional commitments in favor of more subtle resistance. We utilize Walzer’s three responses to dirty hands to examine further how clinicians and consultants can navigate which they choose to embrace. In doing so, we offer early guidance to clinicians and consultants on how to navigate the changing legal landscape in light of stable ethical professional commitments.
In this paper, I show that in the context of nursing, trust isn't a property of the dyadic relationship between nurses and patients, but instead is a feature of nurse-patient-healthcare institution triads. Understanding trust as triadic in the healthcare context is important, I argue, because it emphasizes the pervasive role institutions have on breakdowns in trust between nurses and patients that is otherwise obscured. Nursing exhibits features of both interpersonal and institutional accounts of trust. Nursing demands trust in nurse-patient relationships. And yet, the care nurses provide is a form of labor, highly professionalized, systematized, and resourced by healthcare institutions. Healthcare institutions, such as hospitals, are vested in the experiences of both nurses, their largest workforce population, and patients, their primary consumer. They also play a critical role in shaping the social and physical environments in which patients receive care and nurses work. As such, healthcare institutions are a primary locus for cultivating normative expectations around trust within the nurse-patient relationship. However, the very healthcare institutions that create those normative expectations in the first place, also create conditions that promote trust-betrayal. Thus, healthcare institutions set up expectations for trust relationships between nurses and patients that are nearly impossible for nurses to fulfill. I call this the Dilemma of Professionalized Trust. This dilemma highlights a case of trust that is both interpersonal and institutional, and recharacterizes the nurse-patient relationship from a dyad to a triad, with institutions as a third party, one that intervenes on and shapes the nurse-patient relationship.
Shared Blame: the Preservation and Repair of Trust
In this paper, I show that blame can help restore trust when it is shared between clinicians and institutions in the context of medication errors. I utilize the case of RaDonda Vaught, a nurse criminally charged after accidentally administering a lethal dose of the wrong medication, to illustrate how blame can be shared such that it fulfills what I call its trust-reparative function: the restoration of trust across all participants in the clinician-patient-institution relationship. Shared blame demonstrates what the existing debate on clinician versus institutional responsibility and blame fails to adequately capture, that trust and blame in healthcare are features of networked relationships that both clinicians and institutions are responsible for facilitating between themselves and with the patient. Shared blame, as I characterize it, further makes salient three relational goods that result when both clinicians and institutions respond to errors by sharing blame: 1) acknowledgement that the error, and its consequences for the patient, occurred; 2) appropriate emotional regard for the harm of the error; and 3) the potential for sincere apology. Using Vaught’s case, I examine different social dynamics between clinicians and institutions that occur when blame is either unilaterally or disproportionately discharged between parties rather than appropriately shared. When clinicians and institutions engage in the ideal of sharing blame, it prevents the escalation of further conflict and further enables them to appropriately prioritize repair with the patient and family. Shared blame is necessary for all parties to maintain healthy trusting relationships in the face of imperfect healthcare administration.
A Time for Dirty Hands? Clinical Practice, Clinical Ethics, and the Law in 2025 (With Daniel Kim)
In this paper we argue that Walzer’s conception of dirty hands can help make sense of how clinicians and clinical ethics consultants can respond to the changing legal landscape under the Trump Administration. Good clinical practice and good clinical ethics recommendations are aided by a narrow gap between what ethical reasoning suggests is morally permissible and what the law finds legally acceptable. Under the current Administration the gap between these is expanding at a rapid pace, leading to uncertainty, anticipatory obedience, and a chilling effect among both clinicians and consultants. We suggest that as this gap expands it may be permissible for clinicians and consultants to embrace dirty hands in two possible ways: 1. Clinicians and consultants both can resist the law in their practices in the form of civil disobedience, and have dirty hands for breaking (or recommending to break) the law to continue providing the medical standard of care to patients, trading off on legal consequences for the benefit of practicing with integrity for their professional ethical commitments. 2. Clinicians and consultants can comply with the letter of the law in order to remain available to care for as many patients as they can to the extent possible prescribed by the law. This may entail the use of work-arounds where possible, and trading off on ethical values embedded in professional commitments in favor of more subtle resistance. We utilize Walzer’s three responses to dirty hands to examine further how clinicians and consultants can navigate which they choose to embrace. In doing so, we offer early guidance to clinicians and consultants on how to navigate the changing legal landscape in light of stable ethical professional commitments.