Journal of Religion and Health, Vol. 35, No.

4, Winter 1996

Autonomy,
Hospitality,
and Nursing Care
DAVID M. MATZKO
ABSTRACT'. This essay argues that the virtues and skills of nursing care establish a setting for
hospitality, reciprocity, and the cultivation of a patient's moral agency. Nursing care is able to
provide such a context because it offers a sustained caring presence to the patient. Hospitality is
not a philosophical concept so much as a description of how practices of medical care are per-
formed. Nursing care opens practitioners to personal connections with the patient and family, to
non-medical histories, to a patient's own description of medical events, and to matters of the
spirit.

During a discussion about advanced directives, a group of nurses expressed a

need for such provisions to help patients and their families make decisions
about their care. The nurses agreed that these documents do not represent
finished products. They believed firmly that directives and powers of attorney
ought not to be used as a means to isolate the patient or to bring conversa-
tions about medical care and dying to a close. Hard decisions are not that
simple. Their view was that throughout the contingencies of an illness ad-
vanced directives should provide a basis for continuing conversations among
health-care providers, patients, and their families. Directives only raise is-
sues and their resolution comes together as care progresses. Underlying the
view of these nurses is the understanding that patients and their families
make their decisions in the context of ongoing relationships with their care-
givers. The nurses described these relationships in terms of the advocacy,
friendship, and care that moved across the divides between sickness and
health, crisis and ordinary life, and physical and emotional matters. They
articulated an understanding of the patient-provider relationship which de-
fies the typical conflictual approaches of medical ethics and attendant notions
of patient autonomy.
This essay investigates the underlying assumptions inherent in nursing
care. It argues that nursing establishes a context of care which is unique in
its continuity and sustained interaction between patient and care providers,

David M. Matzko, Ph.D., is Assistant Professor in the School of Arts and Humanities of the
College of Saint Rose in Albany, NY.

9.83 9 1996Institutes of Religionand Health

284 Journal of Religion and Health

and that this context offers a large understanding of the patient's agency in
the health-care setting. The basic claim of the essay is that nursing care is
characterized by a hospitality which enables and empowers patient and fam-
ily to know what they want and to make appropriate choices. This thesis is
set in contrast to theories which make patient autonomy the foundation for
the health-care provider's hospitality. According to these theories, the pro-
vider steps back and makes room for a patient's agency because a patient
enters a health-care environment as an autonomous decision-maker. In con-
trast, I argue that patients enter hospitals as strangers to the medical cul-
ture, to the moral environment, and often to their own illness and disability.
As strangers, their everyday abilities as agents are impaired. Most often,
they do not have the knowledge, language, conceptual skills, or intuition to be
competent agents in the world they have just entered. Nursing care offers
hospitality to persons who are strangers, and through it patients can be en-
abled to gain their bearings in an alien setting and perform as capable moral
agents. Hospitality, rather than patient autonomy, provides the context for
agency.

N u r s i n g care

Most books and articles in medical ethics deal with the role of physicians, the
rights of patients, or the purpose of health-care institutions as a whole. Nurs-
ing is seldom considered. This silence about nursing implies that the profes-
sion has nothing significant to add to understanding diagnosis, treatment,
and the patient in the caregiver relationship. I will wager to say that this
may be t r u e - - b u t only in theory. Physicians are able to do the job of nursing;
yet the inverse is not the case. Doctors have a role in diagnosis, surgery, or in
prescribing care that nurses do not fulfill except when nursing itself becomes
a specialization separate from nursing care. Like doctors, nurses attend to
the body, assess symptoms, suggest some treatments, decide what is good for
particular patients, interact with a particular patient's needs and desires for
care, and fight for patients' lives. Unlike doctors, nurses do not generally
prescribe or direct treatment; they do not, for example, repair coronary arter-
ies or make decisions about chemotherapy.
The nurse adds nothing, formally, to the physician's role in health care. Yet
even when this point is granted, the practices of nursing cannot be said to be
redundant or secondary to the physician. Rather, nursing is a set of specific
practices traditionally considered the physician's art. The physician's art or
craft certainly involves diagnosis and treatment, but also touching the body
with care, presence to suffering, guiding patients through a world of illness
unknown to them, and being an advocate for the sick in the face of disease. In
terms of presence, advocacy, and care, both physician and nurse are called to
attend to the health of a particular person for that person's good. But when a
David M. Matzko 285

physician's own practice is marked by an asymmetry in favor of technical

expertise rather than patient care, the physician's own craft is diminished.
When such asymmetry exists, the nurse sustains what the physician cannot.
The nurse's eight or twelve hours of continuous contact with the patient es-
tablishes a context of habitual care which cannot be reduced to the physi-
cian's periodic assessments. Quite often, the nurse takes a primary role in
attending to a patient and sustaining a context for the health of the patient
as a whole, while a physician or team of physicians provides one isolated
service or another. ~
The required attention to sustained care puts nurses in a pivotal position.
Consider, for example, nurses on any recovery unit. They attend to patients
before and after surgery, a time period spanning anywhere from several days
to a few months. During this time, they get to know patients not only in ways
directly related to their surgery but also in a personal sense. On the one
hand, nursing is becoming increasingly specialized and technological as medi-
cal care itself becomes increasingly technological. Nurses have thorough
knowledge of a patient's medical events and play an important role in main-
taining technological support systems and in sustaining patients' lives by
these means. On the other hand, nurses learn about patients' lives from fami-
lies and friends, about their ways of dealing with illness, and to a great de-
gree, about the non-medical factors that impinge upon illness and recovery.
They teach patients how to care for themselves--from eating right to colos-
tomy care--and unavoidably enter personally into a patient's process of
recovery or decline. This notion of a "personal" relationship to the patient
does not refer to the nurse's affability but rather to special focus on the
particularities of an individual patient. These particularities pertain to ordi-
nary and extraordinary matters, both of sickness and health. They fol~n a
partly tacit, partly explicit knowledge which nurses must take the time to
learn.
Because nurses have sustained contact with their patients, they will recog-
nize problems and avert acute crises by knowing how a patient usually be-
haves and by having a sense of how to interpret a particular patient's cues. A
large part of nursing expertise requires well cultivated intuitions involw~d in
reading the signs of a patient's body.2 These signs are not always even osten-
sibly medical. Nurses know how patients breathe when they sleep; they learn
what pain and complaints about pain mean for one patient rather than an-
other; and they notice slight changes in mood or temperament. This is a level
of diagnosis and care for the body upon which medical care depends. It is a
care that attends to day-to-day details, reads the signs of the body, and comes
to know a patient within a network of family and friends. Nursing care sus-
tains invaluable aspects of the physician's art.
Implied within this brief account of nursing is a contrast between acute
and habitual care. The contrast is not between doctor and nurse but between
one set of health-care skills and another. As the physician's role has been
286 Journal of Religion and Health

defined increasingly by specialization, the relationship of doctor to patient

has been shaped by questions where specialization is most prominent, by
questions of acute care, extraordinary treatment, advancements in technol-
ogy, and crisis situations. The fact that specialization and crisis define medi-
cal-ethical questions about doctor-patient relationships is apparent after
looking at any standard text in the field, covering topics such as human ge-
home research, frozen embryos, euthanasia, assisted suicide, and advanced
directives. While these issues define the physician's role, nurses, on the other
hand, continue to perform the ordinary medical art of daily care and assess-
ment. They perform a less conspicuous type of care, which I call "habitual"
because (1) the care is sustained through time beyond situations of acute
crisis or intervention, and (2) it requires particular habits or virtues of per-
son-to-person care2 Insofar as this care extends through time and requires
virtues which cultivate a care-giving relationship, habitual care has a narra-
tive form. The story-form displays events which transpire in the life of a par-
ticular patient who is cared for by particular caregivers. Like nursing care,
the story-form itself requires time.
To this degree, nursing is characterized not so much by contrasts between
life and death, sickness and health, patient and doctor, but by the need to
integrate a patient into the practices of health-care institutions and to pro-
vide a context where illness might be understood in terms of a life as a whole,
whether one's days of health are past, whether all will be restored, or
whether one has to come to terms with how to live differently or to die.
Through nursing, life and death, sickness and health are not opposed but
connected. In addition, nursing's habitual care does not sustain the common
contrast between a health-care provider's beneficence and patient autonomy.
A nurse's beneficence does not confront the autonomous patient as much as
his or her practices of hospitality welcome a person who is a stranger to ill-
ness and to the operations and languages of health-care institutions. Nursing
care is not set in opposition to the point of view or autonomy of the patient.
More often than not, a nurse aids a patient in developing both a sense of
autonomy and an informed perspective. The next section will develop these
claims through a contrast between crisis and habitual-care models.

Autonomy and hospitality

The acute-crisis paradigm on one hand and the art of habitual care on the
other provide two different frameworks for understanding patient autonomy.
A good representative of the crisis model is Tristram Engelhardt's The Foun-
dations of Bioethics.' Engelhardt argues that patient autonomy ought to be
considered an absolute, a fundamental principle, because he finds that it is a
necessary counterweight against the possibility that a care provider might
impose a view of the patient's own good upon a patient. For Engelhardt, the
David M. Matzko 287

opposition between patient autonomy and the physician's view of beneficence

is generated by the plurality of moral frameworks which affect any health-
care setting. A patient who resists a treatment on moral or religious grounds
will not see a physician's use of the treatment as benevolent, regardless of the
doctor's good intentions. Autonomy is a means to establish and sustain peace,
or at least a moral cease-fire, amid incommensurable convictions about both
the means and ends of medical treatment. Engelhardt's basic concern is to
provide a context for common moral deliberation which will be hospitable to
all persons.
Engelhardt hopes to provide principles for a morally hospitable medical
environment by bracketing particular views of beneficence. In effect, he in-
cludes all perspectives by making all notions of the good or the good life irrel-
evant. He recognizes that inclusiveness must be embodied in the way people
actually interact, and to this end he offers a constructive, albeit a minimal,
account of a non-particular moral community. He constructs a basis for this
community by means of a definition of personhood. According to Engelhardt,
a person is one who is able to participate rationally and peaceably in a neu-
tral moral community. Personhood is defined by membership--in some cases,
former or potential membershipwin this non-sectarian community. Therefore
those who do not participate through certain canons of intelligence (e. g., the
mentally disabled) are on the fringes or cast out entirely. Engelhardt is
straightforward in his proposal. He assumes that this neutral community,
like any other moral community, will include some and require hard choices
about excluding others.
I cite the intentions of Engelhardt's work not to judge whether a truly neu-
tral framework is desirable or achievable or to argue whether his account of
personhood is sustainable. Instead, reference to Engelhardt merely under-
lines the connection between a model of ethics initiated by intractable con-
flicts in a multi-cultural setting and his conception of autonomy. Engelhardt
does not argue that autonomy or moral agency emerges ex n i h i l o . He holds
that agency is developed while living and maturing in a particular moral
community. He argues that it is in such communities that one learns "which
moral and nonmoral goods ought to be pursued, at what costs, and for 'what
goals" and where health-care providers learn their craft and their under-
standing of good health care? But Engelhardt also argues that these particu-
lar views of health care can be detrimental to a patient. In a pluralistic con-
text where common assumptions about goods cannot be assumed, the golden
rule (Do unto others as you would have them do unto you) may in fact be
malevolent. In the face of this problem, Engelhardt proposes that health-care
providers divide their professional role into two levels of moral thinking. On
one level they must have a personal and community formed view of the good
for patients. On the other, they are asked to be bureaucrats or moral geogra-
phers who are able "not do to others what they would not have done to them. "~
This negative statement of beneficence is significant, for Engelhardt's view of
288 Journal of Religion and Health

doing the good for the patient is structured by his principle of autonomy, the
right to be left alone, and the right to decide one's own good.
In Engelhardt's system, patient autonomy and a care provider's view of
moral goods constitute the fundamental conflict underlying questions about
health care. The principle of autonomy requires that health-care providers
back off and put their moral and religious convictions in a private sphere.
The effect is this: while moral agency is developed in community, an agent
enters a health-care setting with a type of autonomy which is not typical of
moral experience. This autonomy seems to preclude what has made moral
agency possible, the embeddedness of goods in a set of relationships and sus-
tained moral interchanges. This concept of autonomy puts patients at a dis-
advantage if they expect moral assistance from their care providers. In En-
gelhardt's defense, we have to grant that moral and religious conflicts do
occur between patients and health-care institutions and that sources of these
conflicts are community- and tradition-bound convictions. There is also no
doubt that many patients have a sense of what has been conferred upon them
as rights which they can use as a defensive tool amid these conflicts. But
while conflicts cannot be denied, they are not representative of the interac-
tion between patient and health-care providers and the function of autonomy
in the health-care setting.
An alternative, more representative account begins not with conflict but
with the habits of care. Habitual care is marked by a shared story between
provider and patient inasmuch as care and healing are a story-formed art.
Care and the search for cure commence when a patient recounts his stories of
health and illness. Story is the means by which scientific abstractions are
applied to the specific ailment of a particular person. A physician probes,
extends, translates, and interprets a patient's stories, and a medical narra-
tive of signs, symptoms, and diagnosis is thus constructed and tested. Within
this story, a physician envisions and proposes a continuing plot line and con-
clusion. Health care is story-formed, and only within the landscape of this
story can patient autonomy and a physician's beneficence take shape. The
patient is both a plot line which the physician is called to bring to a happy
conclusion and an agent who has a role in shaping the story of care. 7
The context of care is the confluence of a patient's personal narrative with
the story of medical care. Amid this confluence, we will find Engelhardt's
conflict between particular goods as they are pursued by health-care pro-
viders and goods as they are perceived by the patient. Engelhardt begins with
the opposing poles of a physician's view of a patient's good and patient auton-
omy, and he attempts to establish a method for adjudicating these conflicts.
But as Edmund Pellegrino and David Thomasma have pointed out, such a
method undercuts the goals of care by setting the care provider and patient
against one another, a Pellegrino and Thomasma argue that the defining char-
acter of medical care assumes a cooperative relationship between caregiver
and patient. In terms of narrative, we can say that any possible conflict about
David M. Matzko 289

care is intelligible only in the context of a shared story. Each story of care is
contingent upon the needs of a particular patient with a particular illness
and with particular convictions about health and care. This particular but
shared story is the primary context for decisions about care.
Because the story of health is shared, Pellegrino and Thomasma are cr~itical
of both paternalism and the principle of autonomy. They are critical to the
degree t h a t both begin with judgements external to the patient-caregiver re-
lationship. They denounce paternalism outright, for it disregards the pa-
tient's agency, and they call autonomy only a relative good, relative, t h a t is,
to the common goods which physician and patient pursue together2 Pel-
legrino and Thomasma provide several guides for fairness and procedures for
informing and granting patients control over treatment. But their interesting
claim is t h a t ultimately the interaction between patients and caregivers de-
pends not on procedures but on the skills and virtues of health-care pro-
viders. While Engelhardt's model assumes disagreement about goods, w h a t
are virtues of care for Pellegrino and Thomasma are intelligible only in terms
of a common good, which they hold is discovered in the relationship between
care providers and patients.
Nursing is a care-giving role which sustains a narrative- or relationship-
oriented context for physicians and nurses alike to pursue the art of medical
care. As noted above, nursing is unique in the way that it takes its time.
Certainly, nurses provide crisis and critical care. But they also attend to pa-
tients when not much is happening "medically," when a crisis is not immi-
nent, when medical care is becoming part of daily life, or w h e n patients are
preparing for tests and t r e a t m e n t or waiting to go home. Nursing care also
cultivates a reciprocity which patients and their families tend not to have
with physician-specialists. Nurses give care as a professional skill, and the
skills or habits of care require the whole person. They are developed not only
through medical training but also in everyday life--life as a parent, as a
friend, in a community of faith, and so forth, s~ When skills of care are per-
formed well, patients and their families recognize this care as a personal
interchange in which they are capable of participating. Their responses vary
from wanting to be sensitive to the nurse's work-load to giving gifts like
hand-made pot-holders or the most hospitable gift of all--providing food for
the nursing staff.
These simple forms of reciprocity are part of a context of common stories of
care. Not all nurses will have reciprocal relationships with all of their pa-
tients, but nursing creates a space where such relationships can be culti-
vated. Nursing care makes room for personal stories to be told, and the sto-
ries abound. Consider the following account by Gail Andrews, R.N., as a
representative example.

There have been periods in m y career when m y respect for, and amaze-
ment of, w h a t the h u m a n body and soul can endure has been sorely tested,
290 Journal of Religion and Health

but Annie "recharged my batteries," so to speak. She was with us for about
three months, challenging and at times very difficult to take care of physi-
cally and emotionally. She became infected, she blew up like a balloon, her
skin broke down. She was on the call light frequently, driving all three
shifts crazy. Was it because she was able to talk to us, to expose us to her
spirit and fight, and very unique sense of humor that endeared her to so
m a n y of her health care t e a m ? . . .
Annie is one of my most affectionate experiences, a success story I'm
very proud of. I still keep in contact with h e r - - s h e is still something else. I
view her as a gift to me of what it (life, nursing, medicine, technology) can
be all about. 11

Andrews' account reveals interesting facets of habitual care. First, this con-
text of care gives a patient an opportunity to speak and to be known as a
person. Second, habitual care takes place in a community of practitioners,
where continuity is sustained from one shift to another. The patient is
brought into community as the very connection between one set of caregivers
and another. Third, nurses come to know not only an illness or disease b u t
the character of a patient and his or her response to the illness. Finally, then,
reciprocity and a shared story emerge. On this level of interaction, the out-
come of care is defined within the context of the relationships among pa-
tients, families, and caregivers. Success is not determined in medical terms
only. Andrews uses the language of body and soul. Her story could have con-
cluded with the death of Annie and still be considered a success if Annie and
her providers had come to terms with the course of her illness.
Within the relationships of care, nurses do not remain morally distant so
that patients can remain unencumbered. Rather, they work as advocates
when patients are unaware of their options, awed and silent about their
needs when face to face with physicians, bewildered by medical technology,
and intimidated by an institution's procedural maze. The work of advocacy is
not contingent on nurse and patient sharing a unified moral perspective.
Nurses offer hospitality to persons who are strangers in the strange land of
medical care, and hospitality assumes that the stranger will be different. Ac-
cording to Dorothy Pickens, R.N., "the hospital is a community unto itself,
with its own rules, language, functions," and the nurse m u s t "welcome" and
acclimate the patient and family to the setting. In this sense, autonomy is not
the basis for hospitality (Engelhardt), b u t vice versa.

Most people who come to u s . . . [Pickens explains] are already under sig-
nificant stress, both physically, emotionally, and socially. In order to have
them successfully get through the hospitalization ordeal, it is important to
give t h e m as much information as possible right from admission. This al-
lows t h e m to actively participate in their care. [The nurse] m u s t explain
frequently the plan of care for the day. Sometimes she must explain from
David M. Matzko 291

minute to minute just what she will be doing at that time. In my practice,
many of my patients have suffered brain damage (from stroke, he:mor-
rhage, injury, tumor) so, even when they can't respond, I tell them what I
am doing (e. g., I am going to turn you now.)J~

Pickens shows that her medical care is a process through which she opens the
way for patients to participate in the events of that care. Care is intimately
connected to hospitality.
Nursing care cultivates a view of patients as capable agents attempting to
make their way through an alien process of medical care. Agency is the key
term rather than autonomy because most patients do not have the knowledge
and intuitions of medicine required to confront their field of choices. The abil-
ity to make choices is a skill. But in the hospital, patients have not had the
chance to develop this skill, just as those of us who are not baseball players
have not developed skills of judging when to swing at a fast ball or those of us
unfamiliar with the stock market will be unequipped to make bold decisions
about trade. Patients are not accustomed to the hospital setting where a par-
ticular set of options are offered and the decisions made.
Nurses typically see patients as capable agents who, nevertheless, need the
help of others. They perceive patients not as self-sufficient but in a network of
family and community which exceeds the context of health care. Engelhardt's
opposition between particular communities is undercut insofar as nursing pro-
vides a space for the hospital culture and the patient's community to interact
in a non-conflictual manner. Nursing care is what happens between crises. One
nurse has learned to suggest that photographs of patient and family be
brought into the hospital room. The pictures are a means through which the
healthy life of the agent enters the world of sickness and disease. These ~ n -
dows into persons' lives empower patients and enhance their existing skills for
coping and for decision-making. Olden, nurses are invited to enter into conversa-
tions with a patient about that patient's everyday life of health as well as bSs or
her story of illness. The nurse becomes a connecting point between life in the
hospital and life before and beyond. Nurses are keenly aware when a family or
network of support is lacking, and they do their best to fill some of the gaps.
While attempting to enable the patient and family in these ways, nurses
often use the language of autonomy to describe not a condition but the goal of
care. "It is truly the responsibility of all health-care workers to promote au-
tonomy for the patient," explains Jeanne Nabozny, R.N. "It is well known
that one of the biggest fears of patients entering a hospital setting is their
fear of loss of control over their bodies and self. "13 Autonomy is fostered,
Nabozny holds, through time spent with the patient and family, listening to
their needs, opening lines of communication, giving information, and trans-
lating medical terms after the patient has had a conversation with a physi-
cian. To the degree that autonomy is established through a relationship with
the care provider, the language of autonomy, as a first principle, breaks
292 Journal of Religion and Health

down. The patient's agency is advanced, not through the self alone, but
through relationships with others. The truly autonomous are those who are
alone. For Engelhardt, the patient as patient always has autonomy, and this
essential state of autonomy provides the right to be left alone. From the per-
spective of nursing care, autonomy is an inadequate description of agency
because a patient requires help in order to be capable of making choices and
to move forward through the course of an illness and care.
The point of nursing care is not to make someone helpless but to empower
and to enhance a patient's control over care. Nurses have an important teach-
ing role, instructing about medical care and offering wisdom about the
trauma of hospitalization. Karla Giramonti, R. N., for instance, points out
that she must help parents of infants in neo-natal intensive care to develop
their identities as parents.

When I meet my patient and patient's parents for the first time, I start
by assessing their needs. This involves the emotional and spiritual needs
as well as physical (or medical) and intellectual (what they need to know
about their child's care). I have found that more often than not the balance
moves from time to time according to what is going on . . . .
Because of the critical nature and potentially long hospital stay of my
clients, the relationship often fluctuates during the stay. The emotional
attachment is often unavoidable and sometimes needed. It is my respon-
sibility as the provider to make sure that attachment does not get out of
hand. It is important to both the family and myself that I remain the nurse
or provider. In the field of caring for newborns, this becomes especially
important. Mothers tend to feel they are not the mother because they are
not caring for their infants. With that they then equate the nurse with that
mother-role. I must affirm this role for them even when I feel attached to
their infant just by virtue of the care I can give and that process of getting
to know that infant because of the time and intensity spent. 14

Giramonti's assessment of needs and her kinds of intervention require a

great deal of intuition and skill. Her care depends upon skill in sustaining a
provider-patient relationship, which in turn will cultivate parents' own care-
giving skills. Rather than terms of protecting autonomy, those of hospitality
offer a better description of these habits. Giramonti welcomes mothers into
the strange environment of the ICU and helps them to be "at home" so that
they can establish themselves as mothers. Giramonti describes hospitality as
an emotional and spiritual task. A woman cannot begin to make coherent
choices about her son or daughter's care until she recognizes herself as
mother. Nursing care undertakes a relationship with patients and their fami-
lies to the end that they will be acculturated in the world of illness and medi-
cal care and as a consequence become capable agents amidst these extraordi-
nary events in their lives.
David M. Matzko 293

Conclusion

Patients are strangers. Health-care providers cannot assume what patients

know about their health, what they expect from care providers, or what out-
comes they desire. Given that patients' wishes are foreign, the first task for a
care provider is not to secure autonomy but to convey hospitality. When one
enters a hospital, a sense of oneself as the primary agent in one's life is chal-
lenged. To a great degree, one becomes a stranger to oneself, while physicians
and nurses take over and begin to chart the story of one's medical life. The
task of hospitality is to integrate patients into their own medical narrative so
that they can become capable agents. In contrast to Engelhardt, Pellegrino
and Thomasma argue that current notions of autonomy tend to skew the
provider-patient relationship. Like paternalism, the principle of autonomy
undermines common efforts by health-care providers and patients in coming
to an understanding of the patient's good. In the context of habitual care, on
the other hand, patients and care providers discover the meaning of illness
and the goals of medicine in the process of undertaking a shared narrative of
care. I have argued that the habits of nursing establish a setting for hospi-
tality, story-telling, reciprocity, and the cultivation of a patient's moral
agency. Nursing care is able to provide such a context because it takes its
time and deals in constancy rather than crisis.
Hospitality is not a philosophical concept so much as a description of how
the practices of medical care are performed. Nursing care gives sustained
attention to a patient, everyday care for the body, comfort, and a sense of
continuity. Nurses read the signs particular to a patient; they are present and
watchful. These habits of nursing open practitioners to personal connections
with patient and family, to non-medical histories, to a patient's own descrip-
tion of medical events, and to matters of the spirit. Through the habits of care
a nurse discovers the story of a patient's life and the patient gains a footing in
the medical narrative he or she inhabits. Nursing care provides a context for
the art of medicine to engage the patient as a particular person. It provides
continuity and a sustained account of agency in contrast to the acute, c~sis-
oriented approach of medical ethics. During the long days between critical
medical events, nurses are there with the patient, giving medical care, talk-
ing, soothing, feeling frustration, laughing, becoming weary, listening, and
teaching. The point is that they are there, and being there shapes a context
for moral discernment.

References

1. See Anne H. Bishop and John R. Scudder, Nursing: The Practice of Caring. New York: Na-
tional League for Nursing Press, 1991, pp. 18-21. William F. May, The Physician's Cowrnant.
Philadelphia: Westminister, 1983, pp. 190-2.
294 Journal of Religion and Health

2. Patricia Benner, ~Discovering Challenges to Ethical Theory in Experienced-Based Narratives

of Nurses' Everyday Ethical Comportment," in Health Care Ethics: Critical Issues, John F.
Monagle and David C. Thomasma, eds. Gaithersburg, MD: Aspen Publications, 1994, pp.
401-11.
3. For an account of the virtues see Alasdair MacIntyre, After Virtue. Notre Dame, IN: Univer-
sity of Notre Dame Press, 1984.
4. H. Tristram Engelhardt, Jr., The Foundations of Bioethics. New York: Oxford, 1986.
5. Ibid., p. 50.
6. Ibid., p. 86.
7. Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowl-
edge. Princeton: Princeton University Press, 1991.
8. Edmund Pellegrino and David Thomasma, A Philosophical Basis of Medical Practice. New
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