Data from Anne R. Bavier, PhD, RN, FAAN, is dean and professor, University of Connecticut School of Nursing, and secretary of the NLN Board of Governors. Nursing Education Perspectives by Anne Bavier. Copyright 2009 by National League for Nursing. Reproduced with permission of National League for Nursing in the format Textbook via Copyright Clearance Center.

Basic definitions

Defining “values,” “morals,” “ethics,” and “bioethics” is useful as a first step in understanding ethics and its relationship to health care. Values are attitudes, ideals, or beliefs that an individual or a group holds and uses to guide behavior. Values are usually expressed in terms of right and wrong, hierarchies of importance, or how one should behave. Values are freely chosen and indicate what the individual considers important, such as honesty and hard work. “Morals” and “ethics” are often used interchangeably, although we make a distinction for purposes of this book. Philosophers and scholars have conflicting views on how to define these terms. Morals are established rules of conduct to be used in situations where a decision about right and wrong must be made. Morals provide standards of behavior that guide the actions of an individual or social group. An example of a moral standard is “One should not lie.” Morals are learned over time and are influenced by life experiences and culture.

Ethics is a term used to reflect what actions an individual should take and may be “codified,” as in the ethical code of a profession. “Ethics” is derived from the Greek word “ethos,” which means habits or customs. Ethics are process oriented and involve critical analysis of actions. If ethicists (persons who study ethics) reflected on the moral statement “One should not lie,” they would clarify definitions of lying and explore whether there are circumstances under which lying might be acceptable.

Bioethics is the application of ethical theories and principles to moral issues or problems in health care. Bioethics (also referred to as “biomedical ethics”) as an area of ethical inquiry came into existence around 1970, when health care providers began to embrace a holistic view of the patient and the rights of patients, in addition to treating and curing disease. Bioethics is concerned with determining what should be done in a specific situation by applying ethical principles. For instance, discussions about genetic testing often have a strong bioethical component surrounding use of knowledge from this type of testing.

Advances in science and medical technologies have allowed health care providers to sustain lives under circumstances that once would have caused a patient’s death. On one hand, these technologies solve some problems, such as assisting with ventilation until a patient is able to breathe without assistance, such as in the case of a life-threatening but reversible condition (e.g., severe pneumonia, moderately severe head injury). Conversely, these advances sometimes create ethical dilemmas for health care providers. For example, a patient may be “kept alive” even when there is no discernible brain activity or hope for the return of spontaneous respiration. Nurses struggle with situations such as these, asking whether a patient should be sustained (“kept alive”) under these circumstances. These situations sometimes raise serious questions for nurses about the meaning of life and what constitutes being “alive.”

A critical attribute of providing care in a professional setting is that professional ethics override personal morals and values. The American Nurses Association (ANA) published a position statement in 1983 that remains in effect today that contains this statement: “The ANA believes the Code [of Ethics] for Nurses is nonnegotiable and that each nurse has an obligation to uphold and adhere to the code of ethics” (ANA, 1994). Holding all nurses accountable to the same ethical code is a means of protecting patients by establishing a clear standard by which nurses make ethical decisions and carry out their duties. The ANA’s Code of Ethics for Nurses is printed on the inside back cover of this text. Provision 2 describes the nurse’s primary commitment to the patient; provision 5 describes the responsibility of nurses to maintain their own integrity. These two provisions are not in conflict, but they do underscore the importance of understanding nursing’s primary ethical obligations to the care of patients.

Nurses, then, must think carefully about their own personal values and morals. Being clear on where one stands personally on a situation will help the nurse make good choices about work environment and types of patients with whom he or she would like to work. For instance, if a nurse has a very strong personal belief that abortion is wrong under any circumstances, he or she would not do well with the requirements of a setting in which pregnancy terminations are performed for genetic disorders. Similarly, if a nurse believes that drug addiction represents a moral shortcoming, seeking employment on an infectious disease unit where many patients have addiction problems would be a poor choice. By understanding their personal values, nurses can anticipate situations in which their personal morals and professional ethics may be in conflict. A wise nurse who is aware of deep personal values and moral standards will make decisions regarding practice setting so that the nurse’s own personal integrity remains intact, while putting patients and their needs first.

Moral reflection—critical analysis of one’s morals, beliefs, and actions—is a process through which a person develops and maintains moral integrity. Moral integrity in a professional setting is a goal in which one’s professional beliefs and actions are assessed and analyzed (reflected on) so that professional ethics continue to mature and respond to changes in practice (Hardingham, 2001). In any complex ethical situation, nurses should analyze their own actions so that they can reduce inner conflicts between their personal values and morals and their professional ethics. A model of nurses’ ethical reasoning developed by Dr. Roseanne Fairchild is featured in Box 5-2.

BOX 5-2 NURSES’ ETHICAL REASONING SKILLS MODEL

A dynamic, ethically based reasoning process became apparent to me over a period of years as I worked with patients and families as an RN in the emergency department and in hospice/palliative care. This dynamic is proposed to involve the interplay of several important internal cognitive processes, as depicted in the nurses’ ethical reasoning skills (NERS) model (Fairchild, 2010). With this theory, I propose that when faced with an ethical dilemma, the professional nurse’s cognitive processes include reflection, reasoning, and a review of competing values, ultimately leading to purposeful action on behalf of patients and families in the nurse’s care.

I developed this model during my doctoral studies at Indiana University, based on my work experiences as an RN, and also based on current evidence in ethical decision making, and in nursing and health systems theory and research (Fairchild, 2010). During my studies, a diverse mix of coursework in ethics and theory seemed to coalesce, allowing me to visualize the complexity of patient care decision-making processes as a unique and ongoing cycle for nurses, akin to a phenomenon called “systems thinking” (Pesut and Herman, 1999). In systems thinking, we continually take experiences in and reflect on them from a holistic, values-based, knowledge-driven stance. Thus what nurses and other health care providers strive to accomplish every day in emergent and/or crisis situations needs to be represented and supported by a fluid, interactive thought dynamic that promotes sound ethical decision making at the “sharp end” (Cook and Woods, 1994) of care.

As challenges in patient care are managed on a daily basis in practice, I believe that practical ethical decision-making skills need to be pushed to the forefront of health care delivery, based on ever-changing characteristics of today’s complex health care systems. In addition, as nurses, our experiences teach us that context is of utmost importance as we strive to follow basic tenets of our profession; that is, to do good, and above all, to do no harm (Gilligan, 1987) on behalf of patients and families. Nurses’ unique commitment and calling to apply both higher level knowledge and humanistic, holistic caring is what sets us apart from the medically based disease model of care. Knowing and cooperatively manifesting our uniqueness allows us to act wholeheartedly and in good faith with other members of the health care team, because we are consciously realizing the complexity, as well as the fragility, of the human caring work we engage in each day.

Roseanne M. Fairchild, PhD, RN, CNE, NE-BC

Indiana State University

Clayton, IN

Fairchild RM: Practical ethical theory for nurses responding to complexity in care, Nurs Ethics 17(3):353–362, 2010.

Pesut DJ, & Herman J: Clinical Reasoning: The Art and Science of Creative and Critical Thinking, Albany, NY, 1999, Dell.

Cook RI, & Woods DD: Operating at the sharp end: The complexity of human error. In Bogner ME, editor: Human Error in Medicine, Hillsdale, NJ, 1994, Lawrence Erlbaum Associates, Inc, pp 255–310.

Gilligan C: Moral orientation and moral development. In Kittay EF, & Meyers DT, editors: Women and Moral Theory, Savage, Md, 1987, Rowman.

When nurses are faced with ethical dilemmas but also encounter institutional constraints that limit their actions, they may experience moral distress (Pendry, 2007). Moral distress is the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; however, as a result of real or perceived constraints, the person participates in perceived moral wrongdoing (Nathaniel, 2002, p. 4). The following situation has several important ethical implications that cause a moral dilemma for the health care team and the family. Examine this scenario for various ethical issues, and think about what parts of this situation might pose a moral dilemma or moral distress for you.

A newborn infant was admitted to the neonatal intensive care unit (NICU). She was born very prematurely and weighs only 520 grams (about 1 pound). The parents want “everything done” for the infant to ensure her survival; the infant, however, has multiple setbacks including serious infections; feeding problems; and then a grade IV intraventricular hemorrhage, which is severe bleeding into the ventricles of the brain. The neonatologists are convinced that the infant will have profound physical, cognitive, and developmental problems if she even survives and ask for a meeting with the parents to discuss discontinuing the infant’s life support. The parents want life support to be continued and for the infant to be a “full code,” meaning that all efforts will be made to resuscitate her in case her heart stops. The nurse understands the parents’ deep desire to give their child every chance to live; however, he also understands the severe physical and neurologic complications of extreme prematurity. He is concerned about pain and suffering the infant may be experiencing because of her numerous treatments and extensive supportive technology. He thinks about the resources in terms of time and money that continuing support of this infant requires, and although he does not like thinking about patient care in those terms, he recognizes the tension he feels about the effort the infant is requiring. The nurse realizes that he dreads going in to work every day to take care of this infant and finds himself dwelling on the situation when he is not at work. After a long shift one night, he goes home and blurts out to his wife, “This just isn’t right, and I don’t know what to do about it.”

This example demonstrates numerous aspects of moral dilemmas and resulting moral distress. The nurse experienced moral distress, a sense of being unable to act in a way that he believes is moral in this situation. The nurse recognized the parents’ desire for their child to live; the possibility of pain and suffering of the infant; the real possibility of severe, long-term problems if she lives; the expense in terms of time and money; the emotional toll of care of the infant; and his own discomfort and sense of helplessness. This nurse also demonstrated that he was reflecting on his own practice and beliefs, which will help maintain his moral integrity. He will also use the lessons from this patient situation as he matures as a nurse, so that similar situations in the future may not be so distressful for him. Critical Thinking Challenge 5-1 refers to this patient situation; once you have studied the remainder of this chapter, you will have additional knowledge, tools, and perspective with which to consider the complexities of this scenario.

CRITICAL THINKING CHALLENGE 5-1

Reflect on the clinical example of the nurse’s moral distress related to the prematurely born infant in the NICU. Now that you have some basic knowledge about ethics, consider these questions:

1. What would a deontologist’s position be with regard to the sustaining of the infant’s life?

2. What would a utilitarian’s position be in this case?

3. What virtues of the nurse do you see at work in this case?

4. What basic ethical principles do you think the nurse may be using in analyzing this moral dilemma?

5. What are your own personal beliefs and values regarding the sustaining of a very premature infant on extensive life support?

6. What are alternative ethical viewpoints that someone else may hold regarding this situation?

7. Who holds the primary responsibility for determining what should happen in this case—the parents or the health care providers? Defend your response from an ethical perspective.

8. What is the state’s (government’s) role in intervening in this type of situation?

To function effectively in today’s complex health care arena, nurses need to understand approaches to moral reasoning, theories of ethics, basic ethical principles, and ethical decision-making models. A significant advance in the professionalization of a traditional occupation such as nursing is the adoption of a formal code of ethics (Baker, 2009). Professional ethical codes such as that of the ANA provide substantial guidance in determining how to respond and act in practice settings when faced with an ethical dilemma. The remainder of this chapter will provide a basic orientation to these complex topics.

Approaches to moral reasoning

Kohlberg’s stages of moral reasoning

Kohlberg (1976, 1986) proposed three levels of moral reasoning as a function of cognitive development: (1) preconventional, (2) conventional, and (3) postconventional. Each of these three levels is then considered in terms of stages. In the preconventional level, the individual is inattentive to the norms of society when responding to moral problems. Instead, the individual’s perspective is self-centered. At this level, what the individual wants or needs takes precedence over right or wrong. A person in stage 1 of the preconventional level responds to punishment. In stage 2, the person responds to the prospect of personal reward. Kohlberg observed the preconventional level of moral development in children younger than 9 years of age, as well as in some adolescents and adult criminal offenders. A more typical example, however, is that of a toddler for whom the word “no” has yet to have meaning as he or she persists in reaching for a breakable object on a table.

The conventional level is characterized by moral decisions that conform to the expectations of one’s family, group, or society. The person making moral choices based on what is pleasing to others characterizes stage 3 within this level. An individual in stage 4 of the conventional level makes moral choices based on a larger notion of what is desired by society. When confronted with a moral choice, people functioning at the conventional level follow family or cultural group norms. According to Kohlberg, most adolescents and adults generally function at this level. “Because it’s the law” is a common explanation of persons operating at a conventional level of moral reasoning.

The postconventional level consists of stage 5 and stage 6 and involves more independent modes of thinking than previous stages. The individual has developed the ability to define his or her own moral values. Individuals who apply moral reasoning at the postconventional level may ignore both self-interest and group norms in making moral choices. For example, they may sacrifice themselves on behalf of the group. Part of their moral reasoning and behavior is based on a socially agreed-on standard of human rights (Haynes, Boese, and Butcher, 2004). In this highest level of moral development, people create their own morality, which may differ from society’s norms. Kohlberg believed that only a minority of adults achieves this level.

Progression through Kohlberg’s levels and their corresponding stages occurs over varying lengths of time for different individuals. The stages are sequential, they build on each other, and each stage is characterized by a higher capacity for moral reasoning than the preceding stage. Kohlberg (1976) suggested that certain conditions might stimulate higher levels of moral development. Intellectual development is one necessary characteristic. Individuals at higher levels intellectually generally operate at a higher stage of moral reasoning than those with lower levels of intellect. An environment that offers people opportunities for group participation, shared decision-making processes, and responsibility for the consequences of their actions also promotes higher levels of moral reasoning. Moral development is stimulated by the creation of conflict in settings in which the individual recognizes the limitations of present modes of thinking. For example, students have been stimulated to higher levels of moral reasoning through participating in courses on moral discussion and ethics (Kohlberg, 1973).

Gilligan’s stages of moral reasoning

Gilligan (1982) was concerned that Kohlberg did not adequately recognize women’s experiences in the development of moral reasoning. She noted that Kohlberg’s theories had largely been generated from research with men and boys, and when women were tested by using Kohlberg’s stages of moral reasoning, they scored lower than men. Gilligan believed that women’s and girls’ relational orientation to the world shaped their moral reasoning differently from that of men and boys. Women do not have inadequate moral development but different development because of their gender. Kohlberg’s inattention to gender differences meant that his theory was inadequate in explaining women’s moral development.

Gilligan described a moral development perspective focused on care. In Gilligan’s view, the moral person is one who responds to need and demonstrates a consideration of care and responsibility in relationships. This perspective differed from the orientation toward justice described by Kohlberg (1973, 1976). In Gilligan’s research on moral reasoning, women most often exhibited a focus on care, whereas men more often exhibited a focus on justice. Gilligan described the differences between women and men’s moral reasoning not as a matter of better or worse, or mature or immature, but simply as a matter of having “a different voice” in moral reasoning.

Gilligan (1982) suggested that women view moral dilemmas in terms of conflicting responsibilities. She described women’s development of moral reasoning as a sequence of three levels and two transitions, with each level representing a more complex understanding of the relationship between self and others. Each transition resulted in a critical reevaluation of the conflict between selfishness and responsibility. Gilligan’s levels of moral development are (1) orientation to individual survival; (2) a focus on goodness with recognition of self-sacrifice; and (3) the morality of caring and being responsible for others, as well as self. The focus of nursing on care as a moral attribute is congruent with Gilligan’s assertion that the dynamics of human relationships are “central to moral understanding, joining the heart and the eye in an ethic that ties the activity of thought to the activity of care” (p. 149). Critical thinking within a caring professional relationship is a sound basis for nursing practice.

Nurses at times combine the care/justice perspective when forced to make ethical decisions. Nurses have shifted from the moral perspective of care to a justice orientation where universal rules and principles are used in moral decision making (Zickmund, 2004). Furthermore, as economics and scarcity of resources shape the delivery of health care, nurses may find themselves less able to use critical thinking, reflection, and higher stages of moral reasoning in their practice setting. The article described in this chapter’s Evidence-Based Practice Note demonstrates that this problem exists across nursing internationally.

EVIDENCE-BASED PRACTICE NOTE

Nurses” Ethical Decision-Making: Conformist Practice

A growing concern exists regarding nurses’ ethical competence. Barriers to ethical practice compromise nurses’ ability to care for patients in a manner that they consider to be moral. De Casterlé, Izumi, Godfrey, and Denhaerynck (2009), an international team of nurse researchers, conducted a meta-analysis using data from nine different studies in four countries to determine how nurses became involved in ethical decision making and action in their daily practice. A meta-analysis is a means of using similar data from different studies that address similar hypotheses and research questions to get results from a larger sample. By combining data, these researchers were able to pool the responses of 1592 RNs who completed the Ethical Behaviour Test, which is based on an adaptation of Kohlberg’s theory of moral development.

De Casterlé, et al. first reviewed the existing literature about nurses’ ethical decision making in practice. They found in their review that nurses typically were often ill prepared to address ethical dilemmas and that nurses do not use critical thinking in making ethical decisions. Nurses were also found to experience conflicts between their personal values and professional ethics, and few nurses were able to express ethical problems to the health care team. In addition, nurses found that their work environment hindered their ability to practice nursing in a manner that they believed was ethical. Heavy workloads, time and financial constraints, and staffing problems all interfered with nurses’ ability to make ethical decision making a priority.

Among the 1592 RNs included in the sample of this meta-analysis, 58 nurses were recruited specifically because they were known to demonstrate high-level ethical reasoning and practice. These nurses constituted the “expert group.” This strategy is known as “purposeful sampling,” to include in a study a very specific group of participants as a comparison group.

The expert group exhibited a significantly higher likelihood to make ethical decisions from a postconventional level of moral reasoning, usually at Kohlberg’s sixth stage. The nonexpert group (the other 1534 nurses) generally preferred moral decisions that corresponded to Kohlberg’s fourth stage, the conventional level of moral reasoning. The nonexpert nurses were significantly more likely than expert nurses to prefer moral decisions from the preconventional level, at Kohlberg’s second stage.

The findings suggested that nurses typically make ethical decisions at a conventional level and that this is an international phenomenon among nurses. The researchers referred to this as “conformist practice” that “excludes a critical and creative search for the best caring answer” (p. 547) to ethical dilemmas. The conventions of practice—medical prescriptions, rules of the nursing unit, and policies and procedures—serve as a framework for practice but should not preclude individualized patient care. The findings of this study confirmed much of what the researchers had seen from their review of the literature: that nurses often face ethical challenges, that workplace conditions hinder nurses from ethical practice, and that there is a growing concern about nurses’ ability to practice ethically. In addition, de Casterlé, et al. found that nurses tend to conform to workplace rules and norms rather than using creativity and reflecting critically on their practice. The researchers suggest that, to provide the best care possible for patients, nurses must develop maturity in their moral reasoning, especially at a time when economic values tend to predominate in shaping workplace decisions.

Data from de Casterlé BD, Izumi S, Godfrey NS, et al: Nurses’ responses to ethical dilemmas in nursing practice: Meta-analysis, J Adv Nurs 63(6):540–549, 2009.

Those who subscribe to utilitarian ethics believe that “what makes an action right or wrong is its utility, with useful actions bringing about the greatest good for the greatest number of people” (Guido, 2006, p. 4). In other words, maximizing the greatest good for the benefit, happiness, or pleasure of the greatest number of people is moral. Utilitarianism assumes that it is possible to balance good and evil with a goal that most people experience good rather than evil. Professional health care providers use utilitarian theory in many situations. Consider, for example, the concept of triage, in which the sick or injured are classified by the severity of their condition to determine priority of treatment. Imagine that there is a plane crash in a remote area in which many of the survivors are severely burned. The local health care facility cannot manage all of the patients, and although air transport is available from a large medical facility 3 hours away, only those with the possibility of surviving can be transported. Those with less serious burns can be managed at a smaller hospital. This means that someone must make the decision as to who will and will not be treated. The most gravely injured will not be treated until those with a reasonable chance of survival are taken care of, although this means that some of the more severely injured will die awaiting care. As a function of utilitarianism, triage is accepted worldwide as an ethical basis for determining treatment.

Often, utilitarianism is the basis for deciding how health care dollars should be spent. For example, money is more likely to be spent on research for diseases that affect large numbers of people than for research on diseases that affect relatively few. Some health care systems, such as the National Health Service in the United Kingdom, depend on utilitarian ethics as one determinant of who receives treatment. For example, inexpensive procedures that benefit large numbers of people, such as cataract surgeries, are easier to access than expensive ones, such as organ transplantations, that benefit a few. A difficulty inherent in utilitarianism is that in the interests of the benefiting of the majority, the interests of the individual or minority, who also deserve help, may be overlooked.