Because ethical issues reflect diverse values and perspectives, they are extremely complex. Ethical questions arise from all areas of life. The ramifications of life-sustaining technology, the population explosion, assisted suicide, euthanasia, genetic engineering, environmental degradation, and allocation of increasingly scarce resources are only a few examples of a host of controversial ethical issues. Ongoing developments in our society such as advances in medical technology, greater recognition of patients’ rights, malpractice cases, court-ordered treatment, and end-oflife decisions call nurses to increase their ethical awareness. Another factor that becomes increasingly important in holistic ethics is the ethical treatment of the other than human world, indeed the Earth as a whole, the health of which is intricately connected to human health.

Unfortunately, ethical dilemmas are usually characterized by the fact that there is no right answer. There are often two or more unsatisfactory answers or conflicting responses. In addition, nurses often find that the expectations of employers, physicians, patients, or other nurses are sources of conflict.¹ Changes in the knowledge that forms the basis of our values and advances in health care are leading to new sources of ethical dilemmas. For example, technologies related to computers and communications have affected patient confidentiality. Life support technology may prolong living, but may also increase suffering and prolong the dying process. In the midst of dealing with sophisticated technology, nurses often find that their focus is more on the machines than on the patient. Such advances have opened the doors to new possibilities for extending or prolonging life, but they also prompt a critical ethical question: Does having the technology always mean it should be used?

Ethical principles serve as a guide for dealing with ethical issues. These principles are basic and obvious moral truths that offer guidance for both deliberation and action. Principles found in major ethical theories include autonomy, beneficence, nonmaleficence, veracity, confidentiality, justice, and fidelity. All of these ethical principles presuppose respect for persons. These principles represent many obligations: to respect the wishes of competent persons, to not harm others, to take actions that benefit others, to produce a net balance of benefits over harm, to distribute benefits and harms fairly, to keep promises and contracts, to be truthful, to disclose information, and to respect privacy and protect confidential information.¹,²

Orentlicher, a physician, lawyer, and ethicist, thinks that there are, at root, only two ways to guide proper behavior: rules and precedents. He notes that rules are designed to support underlying values (e.g., speed limits are set to promote public safety). Rules are attractive because they provide seemingly clear lines of conduct that prevent metaphorical slippery slopes. They also can help to avoid the capriciousness of personal discretion and the obtrusiveness of governmental intrusion in decision making. However, Orentlicher is concerned with the unintended consequences of rules and cites, as an example, the case of mandating pregnant women to undergo certain medical procedures to prevent harm to their fetuses. Another moral concern is the political difficulty of having explicit rules where life-and-death decisions are being made, such as the allocation of scarce organs. Here, society tends to adopt a system of vague precedents that operate under the guise of rules. The appearance of objectivity, which is inherent to general rules, can hide the vagueness of the processes that actually are being used.³

Orentlicher argues that rules sometimes work to the detriment of the value that prompted implementation of the rule in the first place. In fact, this phenomenon is widely considered a kind of natural law: the law of unintended consequences. For example, a medicolegal question might ask whether pregnant women should be forced to undergo treatment to help their fetuses. If forced treatments were endorsed, then some women might avoid prenatal care, thus—and here is the unintended consequence—harming their fetuses. The answer might depend on whether forced treatment would help more fetuses than would be harmed by women who would be driven away from prenatal care. This is but one example of the complexity of ethical decision making.³

Within natural law ethics, the principle of double effect has special importance for nurses. Often, nurses are involved in actions that have untoward consequences. For example, administering a drug to relieve a cancer patient’s pain may shorten the patient’s life. In double effect situations, four conditions must be met before an act can be justified:

Moral problems incorporate a mix of values, risks, benefits, and harms. They are as complex as they are important, include elements of uncertainty and conflict, and defy easy solutions. One must take care with moral decision making because many such decisions are irreversible. Ethics addresses different types of moral problems:

Ethical debate helps to relieve moral uncertainty by clarifying questions and illuminating the ethical features of a situation. Discussion and reflection help to clarify moral dilemmas by revealing general and specific obligations and values. Many factors contribute to the complexity of ethical problems:

Holistic nurses need to know the language of ethics and have the courage to participate fully in ethical decision making. This requires using principles and theory to deal with issues of relationships as well as healthcare concerns. A holistic approach to ethical problems incorporates both thinking and feeling as credible ways of knowing and recognizes a legitimate role for both in ethical decision making. Heart and mind, reason and emotion, need to be attended to when making ethical decisions, appreciating that what one feels in relation to the circumstances of the situation is as important as what one thinks is right or wrong.

Many nurse clinicians turn away in frustration when confronted with the details of ethical theories. Perhaps this is because in the past it has been difficult to see how these historical, philosophical theories relate to contemporary clinical situations. To make these theories meaningful to the work setting, it is helpful to think of situations in which they may apply to current clinical practice.

A number of ethical theories have played a role in Western civilization and have laid the foundation for the development of modern ethics. Aristotelian theory is based on the individual manifesting specific virtues and developing his or her own character. Aristotle (384-322 BCE) believed that an individual who practices the virtues of courage, temperance, integrity, justice, honesty, and truthfulness will know almost intuitively what to do in a particular situation or conflict.⁵ The system of Immanuel Kant (1724-1804) formulated the historical Christian idea of the Golden Rule: “So act in such a way as your act becomes a universal for all mankind.”^5p273 Kant was very much concerned with the “personhood” of human beings and persons as moral agents.

Other theories that are helpful in understanding a holistic approach to ethics include the Utilitarianism Theory of Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873), the Natural Rights Theory of John Locke (1632-1714), and the Contractarian Theory of Thomas Hobbes (1588-1679). Briefly stated, the consequentialist, or utilitarian, view of Bentham and Mill is that the consequences of our actions are the primary concern, the means justify the ends, and that every human being has a personal concept of good and bad. The Natural Rights Theory of Locke was the forerunner of the U.S. Declaration of Independence because it included the tenet that individuals have inalienable rights and that other individuals have an obligation to respect those rights. The Contractarian Theory of Hobbes contends that morality involves a social contract indicating what individuals can and cannot do.^5pp163-169

Another way of viewing ethics is in terms of the two traditional forms: the deontologic style (from a Greek root meaning knowledge of that which is binding and proper) and the teleologic style (from a Greek root meaning knowledge of the ends). The former assigns duty or obligation based on the intrinsic aspects of an act rather than its outcome, meaning that action is morally defensible on the basis of its intrinsic nature. The latter assigns duty or obligation based on the consequences of the act, meaning that action is morally defensible on the basis of its extrinsic value or outcome.

Ethics is the study of the paths of practical wisdom. It is concerned with judgments of good and bad, and right and wrong, based on a philosophic view of the nature of the universe. The holistic view of reality reopens vistas of thought that were dominant in the pretechnologic era, when people were generally closer to their environment and the Earth. The allure of new science and technology sidetracked many of us into primarily linear, rational, unidirectional thought. Furthermore, although technology has provided conveniences and easy solutions, it has also contributed to a tendency to objectify the universe.

Holistic ethics is a philosophy that couples both reemerging and rapidly evolving concepts of holism and ethics. It involves a basic underlying concept of the unity and integral wholeness of all people, and of all nature, which is identified and pursued by finding unity and wholeness within one’s self, within humanity, and within the larger Earth community. Within the framework of holistic ethics, acts are not performed solely for the sake of law, precedent, or social norms; they are performed from a desire to do good freely, to witness, identify, and contribute to unity of the self and of the universe, of which the individual is a part. Encompassing traditional ethical views, the holistic view is characterized by the balance and integration evident in the Eastern monad of the yin-yang mode and in the Western concept of masculine-feminine.

Holistic ethics originates in the individual’s own character and in the individual’s relationship to the universe. In some way, the universe is present totally in each individual; paradoxically, the person is just a small part of that same universe. Gregorios believed that wisdom is a condition in which the self and the world are in communion with each other, within the larger communion, and with the infinite totality of being in its integrity.⁶ A holistic view takes into account the relationship of unity of all beings. Albert Einstein, in the course of a serious illness, was asked if he feared death. He replied, “I feel such a sense of solidarity with all living things that it does not matter to me where the individual begins and ends.”⁷

Holistic ethics is grounded or judged not so much in the act performed or in the distant consequences of the act, as in the conscious evolution of an enlightened individual who performs the act. Understanding that all things are connected, the primary concern is the effect of the act on the individual and his or her larger self (i.e., that unity of which the individual is a part). Unethical acts are those that degrade or brutalize the individual who performs the act and that detract from his or her conscious evolution, which, in turn, degrades the whole. The effect of an unethical act is to make us aware of the deprivation of divinity within humanity and of humanity itself. The unethical act dissolves the unity of matter and takes away wholeness. Acts must be judged in this setting to determine whether they promote wholeness and integration of either an individual or the collective whole. As each of us evolves our own individual consciousness, we assess and direct the evolution of the consciousness of our species and contemplatively examine our relationship with the universal being.