Strand 1 Ethics as decision making for action

Perhaps the most established and strongest trend in ethics education in the health professions is the focus on ethical decision making. This approach to teaching ethics rests on the assumption that ethical practice is primarily about ethical decision making in the same way as clinical reasoning is seen as vital to clinical practice (Ch 7). In ethics education the aim is to teach students how to reason well, using recognised ethical principles, and hence come to ethically justified decisions. It is assumed that this reasoned ethical decision making is the difficult and central part—having come to a decision the health professional will be able to act to put that decision into practice, and what will flow from this is ethical practice.

In this strand, knowledge of ethical principles and theories is emphasised, as are skills in critical thinking, analysis and decision making. Knowledge of legal and regulatory frameworks is also included. There is little overt attention to ethical attitudes, but there is an implicit focus on the value of rational and dispassionate thought, and on the need for detachment from emotion and personal engagement to take an objective, analytical view. Methods of teaching in this approach typically include didactic instruction about principles and models of decision making. Along with this come case studies aimed at showing how principles and models work in practice, and giving students practice in using knowledge of principles and skills of critical thinking to make their own decisions. Teaching ethical decision making using case studies presumes that students will be willing and able to transfer their skills in ethical analysis to the clinical setting as either students or practitioners.

Seeing ethics education as a matter of teaching ethical decision making is a very strong trend in medical education. In the United Kingdom, the United States and Australia, groups of ethicists and medical educators have put forward a core medical ethics curriculum, articulating the basic content areas necessary to an appropriate undergraduate medical ethics course (Culver et al 1985, Ashcroft et al 1998, ATEAM 2001). A great deal of agreement is evident across these three core curricula with each emphasising ethical theories and concepts as well as various specific issues, such as informed consent, truth telling, end-of-life decisions, research ethics, genetic and reproductive technologies, and resource allocation. These knowledge elements of the curriculum are coupled with the skills of ethical reasoning and, to a lesser extent, communication. Beauchamp and Childress’ (2001) framework of four principles governing doctors’ relationships with patients—respect for autonomy, beneficence, non-maleficence and justice—has been a particularly influential moral framework in undergraduate medical ethics teaching. The dominance of this framework is evidence for the prevalence among medical ethics educators of the understanding that ethics is about systematic reasoned decision making.

An emphasis on processes of ethical decision-making education is also the standard approach in allied health ethics education (Chapparo & Ranker 2000, Kenny et al 2007, Eaton et al 2003, Barnitt & Partridge 1997). In physiotherapy, for example, ethical reasoning and models of ethical decision making (Purtilo 1999) are considered to be valuable approaches to preparing students for clinical practice, because they share characteristics and features of clinical reasoning. Edwards et al (2005) suggest a number of parallel processes between clinical and ethical reasoning. Both involve deductive reasoning drawing from ethical theories and principles, and both involve recognition of the patients’ perspective and surrounding clinical context to inform the reasoning steps (Edwards & Delany 2008).

The approach to ethics education in allied health looks very similar to the framework used by medical practitioners. The knowledge base is virtually identical including, for example, informed consent, respect for patient autonomy and confidentiality. Differences can be found in the emphasis that allied health practitioner literature places on combining the analysis of universal moral theories and biomedical principles with the socially constructed realities and perspectives of patients within particular clinical contexts, but these differences are minor in comparison to the similarities.

In nursing, ethics education is also often understood and presented as primarily a matter of ethical decision making, and can look very similar in style and content to medical and allied health ethics. Knowledge areas given attention include truth-telling, informed consent, confidentiality, end-of-life decision making and allocation of resources, just as they are in medicine and allied health (Fry & Johnstone 2002). Students are taught ethical concepts from moral philosophy, such as autonomy; ethical principles in the Beauchamp and Childress tradition; and are introduced to skills and models for ethical decision making (van Hooft et al 1995, Thompson et al 2000). However nursing differs from the other health disciplines in that this decision-making approach is not universally accepted. Indeed, it is hotly contested and rejected by some, and is certainly not the single predominant approach to teaching nursing ethics. One suggested limitation of a rationally based model of ethical decision making in nursing practice—discussed in Strand 2—is its neglect of the role of emotion and compassion as intrinsic elements of ethical action (Doane et al 2004).

Strand 2 Ethics as character and attitude

A quite different understanding of ethics is to see it primarily in terms of the personal character and attitudes of the health professional, rather than in the decisions they make. This approach to ethics has a long history in the Western philosophical tradition, beginning with Aristotle, and is now commonly referred to as virtue ethics. When virtue ethics is the basis for ethics teaching, teaching methods look very different since they aim at promoting attitudes and character traits, virtues such as honesty, compassion and humility, rather than reasoning skills and conceptual knowledge. In this sort of teaching, methods commonly used are experiential (placing students in particular environments to learn what it feels like, involving students in drama, writing of poetry), and reflection (such as journal or diary keeping). There is generally much less attention given to skills and knowledge in this strand of ethics teaching, although arguably both have a role to play in actually manifesting the relevant virtues or attitudes. In theory, virtue ethics does have a place for both conceptual knowledge and reasoning skills: an agent is supposed to think about what would constitute right action by considering what the virtuous person would do, and by aiming for moderation rather than extremes in the virtues, rather than simply acting on impulse. In practice, this does not receive much attention.

In medicine, this understanding of ethics is secondary to ethics as decision making but is nonetheless still present. Core medical ethics curricula emphasise attitudes such as compassion, honesty and integrity. These are seen as fundamental alongside the content areas and decision-making skills outlined in the previous section. Sophisticated virtue ethics that emphasise character traits of the good doctor has increasingly been a feature of the philosophical literature in medical ethics (Drane 1988, Pellegrino & Thomasma 1993, Oakley & Cocking 2001), and this emphasis on developing the appropriate personal qualities can be particularly substantial in universities where medical ethics education is framed as part of professionalism or packaged as an element of medical humanities.

In allied health, there is often an emphasis on professional attitudes, with students explicitly encouraged to adopt a caring and empathic approach. Here there is a quite tangible, overt rationale. The nature of allied health practice is to engage with, motivate, understand and respond to the patient’s individual needs (Poulis 2007, Purtilo 2005, Rogers 2005). Thus, the appropriate attitude is seen as intrinsic to the success of the rehabilitation, acute care and health promotion work of many allied health therapies. Purtilo (2005, p 53) suggests that adopting a caring response as a way of acting ethically means asking ‘What does it mean to provide a caring response in this situation?’. Underlying this question is an assumption that caring for a patient, developing a relationship of trust, and making real contact with patients via a caring presence is a valid way of acting ethically. Teaching students to adopt caring dispositions as a means of guiding actions, involves close examination of the meaning of particular attitudes such as empathy and respect (Peloquin 2005). In allied health, attention to caring attitudes generally occurs in combination with an understanding of rigorous and systematic applications of biomedical principles, which are seen as primary components of the teaching of ethics.

In contrast to medicine and allied health, nursing offers a more radical version of this focus on character and attitude in its ethics of care movement. Ethics of care is more radical than virtue ethics because it involves the explicit rejection of abstract principles and reasoning. Ethics of care understands ethical practice solely as a matter of caring: that is, as an orientation of self towards others or a way of being, which has nothing to do with analytical thought. Ethics of care arose partly out of a sense of threat to the ethical practice of nursing from increasing medical technology. Beginning in the 1970s, a number of nursing theorists, including Jean Watson (1979) and Madeleine Leininger (Leininger & McFarland 1995), began to argue that nursing as a profession had become so focused on the technology of healthcare that it had forgotten about caring for the patient as a person. They argued for a philosophy of care which located nursing ethics entirely in the caring relationship between nurse and patient. On this approach, nursing ethics is not at all about decision making, but rather about engaging in a particular type of interpersonal, deeply caring relationship. Nursing curricula which adopt this approach to ethics characteristically see teaching ethics as a matter of moral development, in particular of cultivating and inculcating attitudes of caring, empathy and engagement (Vanlaere & Gastmans 2007), and place emphasis on the experiential methods mentioned earlier. Ethics of care is unique to nursing: other health professions have not taken up the idea of caring as an ethic in itself. More recently, however, the ethics of care approach has been explicitly linked to virtue ethics (van Hooft 1990), suggesting room for further development in terms of knowledge and skills associated with caring, in contrast to the almost exclusive focus so far on personal characteristics and attributes (although this link does depart from the original philosophy behind ethics of care).

Strand 3 Ethics as advocacy

A third strand present in clinical ethics education is ethics as advocacy. This approach to ethics understands the fundamental ethical role of the health professional as being an advocate for the patient (or client). It is founded on the recognition that most healthcare is delivered in a setting where patients are already vulnerable, tend to be rendered voiceless and powerless by the system, and lack knowledge of their options. Advocacy is seen as the everyday ethical remedy for this situation. The knowledge associated with the advocacy strand of ethics teaching is very similar to that in the decision-making strand. In order to advocate for a patient or client, a health professional needs to know what sort of treatment the patient is ethically entitled to, in terms of information, choice, privacy, confidentiality, respect, access to resources and so on. This tends to be expressed in terms of patients’ rights rather than principles, but the ethical values grounding both are essentially the same. Hence teaching methods similar to those in the decision-making strand are used. However, the skills and attitudes required for advocacy are arguably quite different from those needed for ethical decision making. An effective advocate has to have courage and resilience, skills in negotiation and putting forward a case, and so on.

Although it could be argued that advocating for patients is part of medical practice, particularly in the context of limitations on resources such as hospital beds and specialist appointments, ethics as advocacy is not a prominent idea in medical ethics education.

The idea of the nurse as patient advocate, however, has a very strong tradition (Thacker 2008, Sorensen & Iedema 2007, Hewitt 2002). Hewitt (2002) describes a number of models of advocacy in nursing that either see advocacy as a natural part of the nurse’s role or as a separate task, which requires learning knowledge and skills such as articulating patients’ wishes and fostering a patient-centred approach within the health team on behalf of the patient. Both types of advocacy models rely on nurses having the authority, either through their own role in caring for patients or more explicitly as independent advocates, to influence other members of the health team. Writers in this strand acknowledge that, in reality, this can be difficult (Hewitt 2002, Thacker 2008).

Advocacy is also regarded as important in allied health, where it is linked to the nature of the healthcare being provided (Nelson 2005). For example, in social work, advocacy is seen as a primary component of the profession’s work (Payne 2005). In a study that examined the moral role of physiotherapists in the United States, advocacy was the characteristic most often identified by participating practitioners (Triezenberg 2005). Advocacy was characterised in that study as a means of broadening the responsibilities of physiotherapist from solely focusing on clinical roles to wider patient management tasks. Similarly, the 2020 vision of the Australian Physiotherapy Association (2005) names advocacy as a key characteristic of future physiotherapists. Its description of advocacy includes contributing effectively to the improved health and wellness of patients and communities; recognising and responding to issues where patients require advocacy; and being an advocate for the physiotherapy profession. The last component highlights links between the concept of advocacy and professional identity or promotion of professionalism as ethical and responsible action. Inclusion of advocacy within allied health ethics curricula means teaching skills of determination (Nelson 2005) and knowledge of the different areas that have the potential to impact on patients, including individuals, organisations and, more broadly, society (Glaser 2005). Despite advocacy skills being discussed as components of good—and by implication, ethical—practice, they tend to be taught as aspirations rather than as specific advocacy skills to enhance ethical practice.