Derek Sellman
would be more accurate to say that patients are
more-than-ordinarily vulnerable.
One aspect of those currently described as, e.g. ‘the
vulnerable adult’, ‘the vulnerable child’ and so on, is
that such individuals are perceived by nurses as not
only at risk of harm because of an increased exposure
to type 2 risks of harm but also, in some cases, because
of their reduced or absent capacity to recognize when
they are falling victim to the activities of abuse and/
or because of their reduced or absent capacity to look
after their own interests if they become the victim of
the activities of abuse.
Tliis distinction is important. As a competent adult
I may fall victim to, for example, an unscrupulous
financial advisor who might choose to exploit my trust
in the social institutions that I anticipate will provide
some measure of protection from exploitation. I may
be reassured by a claim by the financial advisor that
he is a member of some professional guild. It is quite
likely that I will accept this claim at face value on the
grounds that I believe there to be such bona fide
organizations designed to protect individuals from
rouge traders. If it turns out that there is no such guild
and that I come to recognize that I have been
exploited then this will confirm my capacity to recog-
nize, albeit too late, that I have been duped. In addi-
tion, and because I am a competent adult, I have the
capability to find out how best to go about seeking
recompense.
That I might not have taken all the steps available
to me to protect myself from such exploitation in the
first place may have been the result of a naive trust
in the system of regulation and the worst that might
be said is that I should have checked to see if she or
he was indeed a member of a bona fide financial
services regulatory authority. My failure to do so illus-
trates both my vulnerability to type 2 risks of harm
and the interdependence between type 1 and type 2
risks of harm.
Those who are the recipients of nursing practice
are not always in a position to either make judge-
ments about protective actions or to know when they
are being exploited. The reduced capacity for self-
protective actions increases a patient’s dependency
on others to act on her or his behalf. Thus the patient
comes to rely on the actions of others for protection
from ordinary everyday risks of harm and on institu-
tional protection from type 2 risks of harm. This
dependency is, of itself, an additional type 2 risk
because the patient is left to trust that those others
have her or his good as a primary consideration. If
those others do not have the patient’s good as a
general aim then the patient remains not only more-
than-ordinarily vulnerable to the activities of abuse
in general but also more-than-ordinarily vulnerable
to the activities of abuse of particular others; others
in whom trust is placed to offer protection from harm.
This is why it is necessary for those charged with the
protection of patients to have certain sorts of dispo-
sitions, dispositions that are consistent with the pro-
tection of more-than-ordinarily vulnerable people.
On this account protection of patients’ particular
vulnerabilities is an essential feature of nursing prac-
tice. Protection is necessary because patients are
more-than-ordinarily vulnerable in both general and
specific ways. To return to an earlier example, protect-
ing an unconscious patient’s airway is a standard fea-
ture of nursing practice. However, there may be
particular characteristics of a given individual that
makes them susceptible to other additional harms as
a result of being unconscious. If these characteristics
are such so as to be identifiable without recourse to
extraordinary means then the nurse would be failing
in their duty of care not to take these individual char-
acteristics into account when planning and imple-
menting care for that particular patient. It requires
recognition of the unusual as well as knowledge of
the general. For the unconscious patient, my compe-
tence to provide care rests not only on my knowledge
of potential and predictable risks of harm but also on
my capacity to recognize the specific as well as gen-
eral vulnerability of a given individual and to act in
suitably protective ways.
Protection is to be distinguished
from paternalism
Despite its origins for good rather than ill, paternal-
ism is currently considered to be generally harmful
because, it is said, it undermines patient autonomy.
The paternalist will assume knowledge of what is best
for a patient without reference to the wishes, the
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