Derek Sellman
Individual patients, different susceptibilities
Recognizing the inadequacy of the adjective ‘vulner-
able’ and replacing it with more accurate terminology
does not of itself remove the problem of imprecision.
For even if one accepts that all patients are more-
than-ordinarily vulnerable it remains true that not
only are individual patients more susceptible to harm
in different ways and at different times but also that
some patients are more vulnerable to particular risks
of harm than others. Generally speaking, but not
invariably, individuals who are unconscious are likely
to be more vulnerable than those who are conscious;
and the same is probably, but not always, true for
people with cognitive or physical incapacities.
Despite variations it is nonetheless possible to say
with some certainty that the unconscious patient is
more-than-ordinarily vulnerable because we know
that a patient who is unconscious is at risk of harm
from a blocked airway and protection from this spe-
cific and predictable source of harm is an important
and necessary action for a nurse to undertake.
Clarke and Driever’s account of
patient vulnerability
Clarke & Driever (1983) attempt to develop an
account of patient vulnerability drawn largely from
social and developmental psychology but their discus-
sion is constrained and their account partial. They
define vulnerability as ‘... the subjective perspective
of the individual [and a]... perceived transaction
between the capabilities and environmental situa-
tions that determines the individual’s wellness-illness
status’ (Clarke & Driever, 1983, p. 210). In other
words, their claim rests upon the assumption that vul-
nerable people are vulnerable because they perceive
themselves to be vulnerable; and on the idea that such
vulnerability is a function of an individual’s percep-
tion of a lack of capacity to protect themselves from
the external environment. They further claim the sub-
jective nature of vulnerability has a psychosomatic
effect on the health of the individual. Those with a
perception of themselves as having a high level of
vulnerability lack the confidence to face the world
and tend to react to their environment in ways that
are ‘... not conducive to healthy development...’
(Clarke & Driever, 1983, p. 211). Whereas the ‘...
individual whose self-perception is one of low
vulnerability ... tends to develop into a healthy, resil-
ient, competent person’ (Clarke & Driever, 1983, p.
211). This is a highly speculative claim and rests, as
they rightly acknowledge, on an extension of the
claims of psychology. Thus, for Clarke and Driever, it
is the perception rather than the reality of vulnerabil-
ity that is an obstacle to flourishing.
Because they locate vulnerability as a subjective
experience and risk as the objective and external
threat to well-being, their construct allows them to
suggest that the function of nursing is to both act on
the external environment (to reduce the risks) and/or
to assist the individual patient to feel less vulnerable
(e.g. by using techniques developed from psycholog-
ical theory to reduce the individual’s perception of
their own vulnerability). In this way it is claimed that
nursing can affect the transaction between the
patient’s vulnerability and their exposure to risk thus
enhancing the patient’s sense of well-being.
They are right in so far as they draw attention to
the fact that to be vulnerable is to be vulnerable to
something and their recognition of vulnerability as a
function of the interaction between the person and
the environment is important. It is also correct to say
that one proper function of nursing is to attempt to
provide a safe environment in which patients can be
nursed and while this might reduce the risk of harm
to an individual patient it does not necessarily reduce
their feelings of vulnerability. Their emphasis on
reducing patients’ feelings of vulnerability is mis-
guided although in doing so they unwittingly illumi-
nate the significant difference between perceptions of
vulnerability on the one hand and actually being vul-
nerable on the other. However, in characterizing vul-
nerability as purely subjective they are unable to
account for those whose capacity to articulate their
subjective experience is in some way compromised.
Thus the three main claims of Clarke and Driever’s
account require further consideration.
Claim I: risk as objective and external
While it is true to say that risk can be objective and
external, neither is a necessary condition. Risk can
© Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 2-10
216