Moral unpreparedness / moral incompetence

The first type of moral problem to be considered here is that of general ‘unpreparedness’ to deal appropriately and effectively with morally troubling situations. What sometimes happens is that a nurse (or other health professional) enters into a situation without being sufficiently prepared or without the moral competencies necessary to deal with the ethical issues at hand ( Johnstone 2015a ). The nurse (or other health professional) may, for instance, lack the requisite moral knowledge (e.g. of moral theories, codes and guidelines), skills and experience (e.g. of ethical reasoning and decision-making, how to interpret and apply ethical principles and standards of conduct), ‘right attitude’ (e.g. ‘excellence in character’, virtue), and moral wisdom (e.g. moral awareness, insight, perception, astuteness) otherwise necessary to be able to deal with the complexities of the ethical issues in the situation at hand (this could also count as moral incompetence or moral impairment, discussed in Chapter 1 of this book). When eventually faced with a particular moral problem, the nurse acts in bad faith by pretending that the situation at hand is one which can be handled ‘with one’s given moral apparatus’ ( Lemmon 1987 : 112). The risks of ‘poorly reflected and inconsistent ethical decisions’ ( Eriksson et al 2007 : 213) and moral error (‘getting it wrong’) in such instances are considerable.

To illustrate the seriousness of moral unpreparedness, consider the analogous situation of clinical unpreparedness. A nurse who is not educated in the complexities of, say, intensive care nursing, but who is nevertheless sent to ‘help out’ and care for a ventilated patient in intensive care, would not only be inadequate in this role, but could even be dangerous. Such a nurse might not have the learned skills necessary to detect the subtle changes in a sedated patient’s condition – changes indicating, for example, the need for more sedation, or the need to perform tracheal suctioning, or the need to increase the tidal volume of air flow or oxygen administration. Neither might this nurse be able to distinguish the many different alarms that can go off on the high-tech equipment being used to give full life support to the patient, or to detect any malfunctioning of this sophisticated equipment. Without these skills, a nurse working in intensive care would be likely to place the life and wellbeing of the patient at serious risk.

The argument of the seriousness of unpreparedness also applies to the complexities of sound ethical reasoning and ethical health care practice generally. Such a nurse, left to deal with a morally troubling situation, would not only be inadequate in that role but, as the intensive care example shows, his or her practice could be potentially hazardous. Without the learned moral skills necessary to detect moral problems and to resolve them in a sound, reliable and justifiable manner, an unprepared nurse, no matter how well intentioned, could fail to correctly detect moral hazards and the risk of moral injuries occurring in the workplace, and therefore fail to act or respond in a way that would prevent adverse moral outcomes from occurring.

The kinds of preventable adverse moral outcomes or ‘near misses’ that can occur as a result of nurses’ (and other allied health professionals’) moral unpreparedness to deal appropriately and effectively with moral problems in health care contexts are well documented in the nursing, bioethical, legal and other related literature. To give just one stand-out example, consider the notorious case of the Chelmsford Private Hospital in Sydney, Australia. In this case, many people were left permanently damaged and scarred – some even died – as a result of receiving deep sleep therapy (DST) prescribed by Dr Harry Bailey, a consultant psychiatrist, who later committed suicide in connection with the scandal that was eventually uncovered ( Bromberger & Fife-Yeomans 1991 ; Rice 1988 ). It is now known that approximately one thousand patients were ‘treated’ with DST at this hospital. It is also known, as revealed as early as 1977 by the current affairs television program 60 Minutes , that many of these patients did not receive the standard of care and treatment they were entitled to receive. Among other things – including the deaths of seven people between 1974 and 1977 – the 60 Minutes program revealed that ‘recognised standard precautions for the safety of patients were not taken; and that patients received the treatment without their consent’ ( Bromberger & Fife-Yeomans 1991 : 142). In the Chelmsford Royal Commission that was eventually established in 1988 to ‘examine the provision of Deep Sleep Therapy and the administration of Chelmsford Private Hospital’, it was confirmed that:

The signature of some [consent] forms was obtained by fraud and deceit. Some were signed by people whose judgment was compromised by drugs. Some patients were even woken up from their DST [Deep Sleep Therapy] treatment to complete their authorisation. Other patients were treated contrary to their express wishes and some were treated despite the fact they had specifically refused the treatment. (Commissioner Slattery, cited in Bromberger & Fife-Yeomans 1991 : 171)

Nursing care was also seriously substandard. In one notable case, the nursing care had been so negligent that a patient developed severe decubitus ulcers between her knees, which became ‘glued’ together as though they had been skin grafted. The former patient recalled:

I was having hallucinations about a lot of coloured ribbons and trying to climb out through them finding the world again. I woke up in a bath tub and two nurses were bathing me. I felt really dirty. One of the nurses said, ‘My God, look at her knees.’ I looked down and they were joined together. The nurses gently pulled them apart. ( Bromberger & Fife-Yeomans 1991 : 94)

Another example of the substandard nursing care that was provided can be found in the experiences of another patient, Barry Hart, outlined in the following statement read to the New South Wales Parliament in 1984:

Basic, commonsense nursing practice was ignored. Patients were sedated for ten days and given no exercise during this period. They were incontinent of faeces and urine most of the time and were left lying incontinent of faeces until they woke up. There was no attempt to maintain a fluid balance. Patients wet the bed and remained lying in the urine until the sheets were changed. The staff made an approximation of whether the patients were actually passing urine (i.e. a fluid output) by seeing how wet the bed was. (cited in Rice 1988 : 47)

One of the troubling things about the whole Chelmsford scandal is that rumours about Dr Bailey’s unscrupulous practices had been circulating for years, yet nothing was done about it ( Bromberger & Fife-Yeomans 1991 : 176). Equally disturbing is the fact that it was not until 1988 – 24 years after the investigated death of the first ‘deep sleep’ patient, and only after ‘treatment’ had led to the deaths of 24 patients – that a Royal Commission was set up to investigate the allegations concerning the patient abuse that was subsequently proved to have occurred at Chelmsford Private Hospital ( Bromberger & Fife-Yeomans 1991 : 162). Significantly, in the Royal Commission of Inquiry that was conducted, and in the report on its findings, it was revealed that between 1963 and 1979 only two nurses took action in an attempt to expose the unscrupulous practices they had observed ( Report of the Royal Commission into Deep Sleep Therapy 1990 : 127). There is room to suggest here that, had the nursing staff been better prepared to recognise and respond effectively to violations of professional ethical standards, the trauma and suffering experienced by the patients at Chelmsford could have been prevented.

Not all adverse moral outcomes occurring in health care contexts are as ethically dramatic as those that occurred in the Chelmsford Private Hospital case, however. Preventable adverse moral outcomes can and do occur on a much more commonplace level in the health care arena, as examples to be given in the following chapters of this book will show.

Moral blindness

A second type of problem nurses sometimes encounter is what might be termed ‘moral blindness’ (also called ‘ethical blindness’). A morally blind nurse (or other health professional) is someone who, upon encountering a moral problem, simply does not see it as a moral problem. There are four possible explanations for this. First, the nurse may perceive the problem confronting her as either a clinical or a technical problem only. A tendency by health professionals to sometimes ‘translate ethical issues into technical problems which have clinical solutions’ was first recognised over four decades ago ( Carlton 1978 : 10), and persists in various forms to this day. A second (and possibly related) explanation relates to a phenomenon termed ‘inattentional blindness’. First described by Neisser (1979) and later popularised by US researchers Chabris and Simons (2010) in their now famous ‘invisible gorilla’ experiment (this can be viewed at http://www.theinvisiblegorilla.com/gorilla_experiment.html ), inattentional blindness fundamentally involves ‘failing to see things that are in plain sight’ on account of the observer not expecting to see them . Just as inattentional blindness has implications for patient safety in clinical settings ( Jones & Johnstone 2017 ), so too does it have implications for moral safety in healthcare contexts. Onlookers may, for instance, ‘not see’ the ethical dimension of an issue because, quite simply, they are not expecting to see it and are not looking for it. A third explanation may lie in the moral psychology of individuals who, lacking moral insight and awareness (and some may argue, intrinsic moral character and moral will as well), are ‘ethically blind’ to their previous behaviours involving ethical failures. Similar in nature to the problems of moral disengagement and moral fading (both discussed below), instead of reflecting on their previous questionable conduct and lack of moral sensibilities, they normalise them ( Chugh & Kern 2016 ; Mortensen 2002 ). Borrowing from the patient safety literature, this outcome may be referred to as ‘the normalisation of deviance’ ( Banja 2010 ; Price & Williams 2018 ) – in this case of morally questionable acts. The normalisation of deviance involves a process of insensitivity occurring imperceptibly – sometimes over years – until a point is reached where a deviant practice ‘no longer feels wrong’ ( Price & Williams 2018 : 1).

A fourth and final explanation may relate to the phenomenon of what Margaret Heffernan (2011) has influentially described as ‘willful blindness’. Willful blindness is a legal concept that dates back to the 19th century and holds that a person is responsible for something that they ‘could have known, and should have known’ but instead ‘strove not to see’ ( Heffernan 2011 : 2). Heffernan (2011 : 1) explains that, in practice, willful blindness involves the denial of truths that are too painful or too frightening to confront even though these truths ‘cry out for acknowledgment, debate, action and change’. One of the insidious effects of willful blindness is that ‘bad acts’ are not committed in some dark and hidden way so that people cannot see them, but rather in the plain view of people who ‘simply [choose] not to look and not to question’ ( Heffernan 2011 : 1).

Moral blindness can be likened, in an analogous way, to colour blindness. Just as a colour-blind person fails to distinguish certain colours in the world, a morally blind person fails to distinguish certain ‘moral properties’ in the world. In short, they have a ‘moral blind spot’. Perhaps a better example can be found by appealing to a set of imageries commonly associated with Gestalt psychology and theories on the nature of perception. Consider the two following drawings, which are popularly presented in psychology texts to demonstrate certain perceptual phenomena, including perceptual organisation and the influence of context on the way in which an object is perceived.

The first of these drawings ( Fig. 5.1 ) depicts what initially appears to be a white vase or goblet against a black background; after a more sustained glance, the drawing changes (or rather, one’s perception ‘shifts’) and what is perceived instead are two black facial profiles separated by a white space. Some people see the alternating vase–face images relatively quickly and easily, while others struggle to shake off what for them remains the dominant image (i.e. either the vase or the faces).

Reversible figure and background

(Source: John Smithson 2007/ commons.wikimedia.org/wiki/File:Rubin2.jpg )

The second ambiguous drawing ( Fig. 5.2 ) depicts what can be seen as either a duck or a rabbit. As with the vase–face drawing, some people see the alternating duck–rabbit images relatively easily, while others literally get ‘stuck’ with a dominant perception of either the duck or the rabbit.

Ambiguous stimulus

(Jastrow, J. (1899). The mind’s eye. Popular Science Monthly , 54, 299–312)

Psychologists claim, however, that people’s perceptions can be altered by context – in this instance, by showing photographs before the ambiguous drawings are viewed. They claim that, on an initial viewing of an ambiguous drawing, a majority will report seeing one dominant image first – for example, the duck. If subjects are shown photographs of the alternative image before seeing the drawing, however, almost all see the alternative image (e.g. the rabbit) first. The same ‘reversals’ can be achieved by conditioning subjects with photographs to see the alternative image (e.g. the duck / rabbit) first (see also Atkinson et al 1983 : 147).

It is not the purpose of this analogy to advance a theory of moral perception but rather to highlight the possible risks of impaired moral perception in health care contexts. Drawing on this analogy, there is room to suggest that health professionals (including nurses) are sometimes so conditioned by the ‘clinical imagery’ (context) around them that, when they do encounter a bona fide moral problem, it tends to be perceived not as a moral problem, but as a clinical or a technical problem and, as such, one requiring a clinical solution, not a moral solution. Some health professionals have a healthy perception of the alternating moral–clinical images depicted by a given scenario; others, however, remain stuck with a dominant clinical image and do not see the alternative moral image , which for them is less discernible. One unfortunate consequence of this is that technically correct decisions are sometimes made at the expense of morally correct decisions.

The extent to which clinical perceptions and judgments can dominate over moral perceptions and judgments can be illustrated by the once-common practice of defending ‘Do Not Resuscitate’ (DNR) directives (also called ‘Not For Resuscitation’ or NFR directives) on hopelessly or chronically ill patients on medical grounds (‘medical indications’) alone. In the past many doctors and nurses perceived DNR directives as involving a clinical issue , not a moral issue , and, as such, one to be decided by doctors, not ethicists. The clinical–moral Gestalt problem became apparent at an Australian nursing law and ethics conference in 1988. After presenting a paper on the nature and moral implications of DNR / NFR directives, a keynote speaker was approached by several registered nurses with what, at the time, became a familiar and distressing comment: ‘My God! I had never thought about it [DNR / NFR] as a moral issue before … What have I done?’; other nurses wanted to challenge or attack the view that DNR / NFR directives involved moral considerations and moral decisions. The then state president (in Victoria) of the Australian Medical Association, Dr Bill McCubbery, was prompted to respond to the issue, and is reported as saying that ‘NFR decisions had to depend on professional judgment’ ( Schumpeter 1988 : 21).

Today there is a much greater recognition of the moral dimensions of DNR / NFR directives and the degree to which such directives are informed by moral considerations (see the discussion on DNR in Chapter 9 of this book). The once common view that DNR / NFR decisions are based ‘simply’ on medical concerns / indications (not ethical concerns) and are more a matter of ‘good medical judgment’ (rather than – or as well as – sound moral judgment) is rarely advanced in contemporary debate, at least not credibly. Nevertheless, this kind of thinking persists in regard to other issues. For example, in 2001, in a highly publicised surgery ban imposed on smokers by doctors in the Australian state of Victoria, surgeons were reported as defending their stance by arguing that:

Medical concerns, not moral judgments, were the bottom line in banning smokers from a range of life-saving treatments. ( Chandler 2001 : 9)

The specific treatments banned, in this instance, were reported to include artery by-passes, coronary artery grafts, lung reduction surgery and lung and heart transplants ( Taylor 2001 : 4). Over a decade later, the issue of clinical judgments versus moral judgments in regard to treating smokers (and other patients with ‘lifestyle’ diseases) captured national headlines in the UK, after that country’s National Health Service (NHS) reportedly banned general practitioners (GPs) from performing minor surgeries on patients who were smokers or who were obese ( Adams 2013 ; Campbell 2012 ; Palmer 2012 ). The authorities and GPs supporting this stance denied this was a case of making moral judgment about people’s ‘lifestyle choices’ or about how valuable they thought the patients’ lives were, or whether they thought such patients did not ‘deserve treatment’ because of having brought their health problems on themselves ( Adams 2013 ; Campbell 2012 ; Palmer 2012 ). Rather, it was contended, their stance involved a ‘purely medical decision’, based ‘on the fact’ that evidence shows people who smoke or who are overweight are at ‘greater risk of developing serious complications and recover more slowly from surgery’ ( Palmer 2012 ).

The issue of ‘moral blindness’ among nurses is an important one since, as with the problem of moral unpreparedness, it can result in ‘wrong decisions’ being made and otherwise preventable moral harms occurring. This problem is not insurmountable, however. Just as people can be ‘conditioned’ to see the white goblet rather than the two black faces in the ambiguous drawing shown in Fig. 5.1 , or of the rabbit rather than the duck in the ambiguous drawing shown in Fig. 5.2 , so too can nurses be ‘conditioned’ (or rather educated) to see the moral dimension of an ambiguous scenario which can be perceived as involving either a moral problem or a clinical or technical problem. Arguably, the best way to achieve such a Gestalt moral shift in perception is by appropriate ethics education and reflective ethical practice.

Moral indifference and insensitivity

A third type of problem which nurses may encounter is that of ‘moral indifference’ and ‘moral insensitivity’. Moral indifference is characterised by an unconcerned or uninterested attitude towards demands to be moral; in short, it assumes the attitude of: ‘Why bother to be moral?’ The morally indifferent person is someone who typically refrains from expressing any desire that certain acts should or should not be done in all comparable circumstances ( Hare 1981 : 185). Moral insensitivity, in turn, similarly reveals itself in the everyday failure to respond to the suffering of others, in refusing to understand others, and in ‘the casual turning away of one’s ethical gaze’ ( Bauman & Donskis 2013 : 9) – in other words, assuming the stance of a morally passive bystander. Moral insensitivity in this instance is compounded by what Bauman and Donskis (2013 : 11) describe as the ‘non-perception of early signals that something threatens to be or is already wrong with human togetherness and the viability of human community’, and that if nothing is done ‘things will get still worse’. Moral indifference is different to moral blindness in that the individual ‘sees’ a moral issue but is indifferent to it.

An example of a morally indifferent and morally insensitive nurse would be a nurse who failed in his or her everyday practice to respond to the suffering of patients, refused to understand them, and blithely turned away from promoting and protecting their moral interests. Such a nurse may, for example, be unconcerned about and uninterested in alleviating a patient’s pain, or be unconcerned about or uninterested in the fact that a DNR directive or a directive to perform electroconvulsive therapy (ECT) has been given on a non-consenting patient, or be unconcerned about and uninterested in any form of violation of patients’ rights. As well as this, a morally indifferent and insensitive nurse would refrain from expressing a desire that anything should be done about such situations.

The problem of moral indifference and moral insensitivity in nursing was first captured by Mila Aroskar (1986) in her classic article ‘Are nurses’ mind sets compatible with ethical practice?’ Aroskar (1986 : 72) cites the findings of a study undertaken in the late 1970s which showed that nurses tended to defer to institutional norms ‘even when patients’ rights were being violated’. She also points out that, despite the North American nursing profession’s formal commitment to ethical practice (as manifested, among other things, by its formal adoption of various codes and standards of practice), arguments were still widely heard among nurses that ‘ethical practice is too risky and requires a certain amount of heroism on the part of nurses’ ( Aroskar 1986 : 69). Although written over two decades ago, Aroskar’s words still apply today. For example, the former secretary of the Australian Nursing Federation (ANF), Jill Iliffe, had cause to reflect (2002 : 1):

What do you do when something happens that you know to be wrong, unethical or inappropriate? […] A colleague behaves unprofessionally; health care is provided that you know to be inappropriate; a decision is made that is ethically questionable; there is an adverse outcome that could have been avoided, or was perhaps even the result of negligence. What do you do? It is often a difficult decision to make, particularly when the other person or persons are more senior to you and in a position of power and authority.

More recently, a much cited review of the literature on nurses’ ethical reasoning and behaviour found that nurses still tend to be ‘conformist’ in their practice and feel hindered by ‘dominance within the medical profession, a stressful work environment, insufficient resources, time and workload pressures’ ( Goethals et al 2010 : 644; see also Dierckx de Casterlé et al 2008 ).

The retreat by nurses into moral indifference and insensitivity (moral blunting), while not condonable, is understandable. There are many examples that demonstrate the kinds of difficulties that nurses might find themselves in when attempting to uphold morally responsible professional practice, and the ultimate price that can be paid for taking an independent moral stand on a matter. Many nurses know (and have possibly personally experienced) the forces that can be brought to bear when taking a moral position which conflicts with established hospital norms and etiquette. It is, then, perhaps understandable (even though inexcusable) that nurses become morally indifferent to breaches of ethical standards and unjust practices in health care domains. Compounding this situation, institutional and legal constraints can sometimes make it difficult for nurses to uphold the agreed ethical standards of the profession ( Johnstone, 1994b, Johnstone, 2002 ). The price paid for acting morally or for taking a moral stand can be high, as other examples to be given in the chapters to follow will show. What this signifies, however, is not that nurses should abandon the demands of morality; rather, they should seek ways in which they can uphold morality’s demands safely and effectively. This issue will be considered in more depth in Chapter 11 of this book.

Moral disengagement

A fourth problem that may be encountered is that of moral disengagement. The notion of ‘moral disengagement’ (like moral fading, which will be considered under the following subheading) was first articulated by Canadian-born psychologist Albert Bandura, 1986, Bandura, 1990, Bandura, 1999 ; Bandura et al 1996 ) and is broadly defined as a process whereby an individual convinces himself / herself through a process of elaborate self-serving rationalisations that ethical standards do not apply to them in given situations and thus they do not need to self-censure. Bandura contends that moral disengagement may centre on one or all of the following:

(a) The reconstrual of the conduct itself so it is not viewed as immoral, (b) the operation of the agency of action so that the perpetrators can minimize their role in causing harm, (c) the [distortion of] consequences that flow from actions, (d) how the victims of maltreatment are regarded by devaluing them as human beings [dehumanization] and blaming them for what is being done to them. ( Bandura 1999 : 194)

Moral disengagement from self-censure is thought to be a gradual process (i.e. it occurs over time) with people often not even recognising that they are changing. As Bandura (1999 : 203) explains, ‘Disengagement practices will not instantly transform considerate people into cruel ones’. He goes on to use the example of a prison guard who assists with the executions of prisoners on death row. Over time, the guard became ‘less bothered’ by his role, ultimately seeing it as ‘just another job’ ( Bandura 1999 : 204).

More recent work on the subject has revealed the problem of moral disengagement to be a significant and growing problem worldwide at all individual, collective and institutional levels. Today there is a plethora of research (too numerous to cite here) on the subject of how, when, where and why people selectively disengage their moral self-regulation without feeling guilt or shame. Significantly this research has been conducted from a range of disciplines and domains including business, organisational behaviour, sports psychology, criminology, military psychology, insurgent terrorism, child and adolescent development, by-stander effect, refugee aid, police repression and cyberbullying, to name some of them (see, for example, Antony 2017 ; Enemark 2017 ; Hindriks 2015 ; Kavussanu & Stanger 2017 ; Meter & Bauman 2018 ; Moore, 2008, Moore, 2015 ; Moore et al 2012 ; Neal & Crammer 2017 ; Soares et al 2018 ; Thornberg et al 2016 ; Wang, Ryoo, Sweare, Turner, Goldberg, 2017, Wang, Wang, Ungvari, Ng, Wu, Wang, Xiang, 2017 ; Zapolski et al 2018 ).

The problem of moral disengagement, as described above, has only recently been considered in the nursing literature ( Fida et al 2016 ; Hyatt 2017 ). Although limited, this work has highlighted the risks of moral disengagement in nursing – in particular, its role in enabling nurses to rationalise their non-compliance with the profession’s ethical standards and hindering the conscientious and civic behaviour otherwise expected of them. Examples of morally disengaged behaviours by nurses include academic dishonesty, cheating in both classroom and clinical settings, workplace bullying, theft from patients, the misappropriation of pharmaceutical products from work, discrimination, and rude and uncompassionate behaviour towards patients ( Johnstone, 2016b, Johnstone, 2016c, Johnstone, 2017 ; Lipscomb 2016 ; see also the 2016 special issue of Nursing Philosophy on ‘Dishonesty and deception in nursing’ at https://onlinelibrary-wiley-com.easyaccess1.lib.cuhk.edu.hk/toc/1466769x/17/3 ). Of particular concern, however, are the risks that moral disengagement poses to patient safety and the organisational culture of health care institutions ( Hyatt 2017 ). Whether moral disengagement can be effectively remedied by targeted interventions designed to prevent or counteract its incidence and harmful impact is not clear. Research suggests, however, that those with a strong moral identity tend to be strongly motivated to be ethical and thus are less prone to moral disengagement, in contrast with those whose moral identity is weak ( Hindriks 2015 ).

Moral fading / ethical fading

A fifth problem, which in several respects stands as both a consequence of and a component of moral disengagement, is ‘moral fading’ (also termed ‘ethical fading’). Ethical fading fundamentally involves self-deception (encompassing ‘language euphemisms, the slippery-slope of decision-making, errors in perceptual causation, and constraints induced by representations of the self’). This self-deception, in turn, plays a fundamental role in people overestimating their disposition towards being ethical and underestimating their capacity to engage in unethical behaviour ( Tenbrunsel & Messick 2004 ).

Research on moral fading (like research on moral disengagement) has shown that people are often not as ethical as they think they are. Explaining this observation, Tenbrunsel and colleagues (2010 : 154) write:

People believe they will behave ethically in a given situation, but they don’t. They then believe they behaved ethically when they didn’t. It’s no surprise, then, that most individuals erroneously believe they are more ethical than the majority of their peers.

Research also suggests that when people are faced with extreme situations (e.g. public health emergencies, unjust organisational cultures), they will abandon ‘the illusion that certain values are infinitely important’ and make moral compromises ( Tetlock 2003 : 322) – in short, their otherwise ordinary ethical standpoints ‘fade’.

The problem with moral fading is that even ‘good’ and well-intentioned people can find themselves crossing ethical boundaries and being ‘ethically faded’ and ‘ethically adrift’ without even realising it ( Moore & Gino 2013 : 55). Powerful and subtle influences can, for example, misdirect an individual’s inner sense of right and wrong and (mis)lead them to believe that they are being ethical when they are not ( Moore & Gino 2013 ; Tenbrunsel & Messick 2004 ).

Contributing to and facilitating ethical fading are what Moore and Gino (2013) have termed in another context moral neglect , ( faulty) moral justification (manifesting as self-verification), and ultimately moral inaction . In the case of moral neglect, individuals succumb to the social norms of the day, eager to ‘fit in’ and to behave in socially approved ways, and lose sight of the possible moral consequences of their behaviour. Wanting to retain membership (and the approval) of the ‘in-group’, the grounds are set for moral disengagement, moral hypocrisy, moral fading and ultimately moral inaction. In addition, there is the problem of what Moore and Gino (2013) describe as ‘organisational aggravators’, which include organisational socialisation and identification, role expectations, goal orientation and group loyalty – all of which can, in various ways, be morally degrading and corrupting. Taken together, these processes can create a powerful barrier to ‘doing the right thing’. In the case of nurses, they can also work to accustom individuals to ‘tolerating behaviors that are outside the realm of considerate conduct’, often without their even being aware of it ( Felblinger 2008 : 238).

Amoralism

A sixth type of moral problem which nurses might encounter is that of ‘amoralism’, which is characterised by an absence of moral concern and a rejection of morality altogether (a position significantly different from immoralism , discussed below, which accepts that morality exists, but violates its demands). An amoral person is someone who refrains from making moral judgments and who typically rejects being bound by any of morality’s behavioural prescriptions and proscriptions. If an amoralist were to ask: ‘Why should I be moral?’ it is likely that no answer would be satisfactory.

A nurse who is an amoralist would reject any imperative to behave morally as a professional. For example, the amoral nurse might reject that he or she has a moral duty to uphold a patient’s rights. The amoral nurse would also probably claim that it does not make any sense even to speak of things like a patient’s ‘rights’ since moral language itself has no meaning. The amoralist’s position in this respect is analogous to the atheist’s rejection of certain religious terms. The atheist, for example, would argue against uttering the word ‘God’, since it refers to nothing and therefore has no meaning. Such an atheist might also claim that there is no point in engaging in a religious debate on the existence of God, since there is just nothing there to debate. The amoralist may argue in a similar way in relation to the issue of morality.

It can be seen that the amoralist’s position is an extreme one, and one which is very difficult to sustain. (Even thieves, who may appear amoral, act on the ‘moral’ assumption that it is ‘good / right’ to steal.) Perhaps the most approximate example that can be given here is that of psychopaths or frontal-lobe-damaged persons who simply lack all capacity to be moral – an issue that has been comprehensively explored in the neuroethics literature (see, for example, Damasio, 1994, Damasio, 2007 ; Gazzaniga 2011 ; Gellene 2007 ; Koenigs et al 2007 ; Lehrer 2009 ; Strueber et al 2007 ). If amoralism is encountered in health care contexts, it is likely that very little can be done, morally speaking, to deal with it. The only recourse in dealing with the amoral health professional would be to appeal to non-moral censuring mechanisms such as legal and / or professional disciplinary measures.

Immoralism

A seventh type of problem that might be encountered by nurses is ‘immoralism’ or immoral conduct. At its most basic, immoral conduct (also termed unethical conduct ) can be defined as any act involving a deliberate violation of accepted or agreed ethical standards. As previously discussed in Chapter 1 of this book, immoralism can encompass both moral turpitude and moral delinquency . Moral turpitude may be more specifically defined as:

anything done knowingly contrary to justice, honesty, principle, or good morals … [or] an act of baseness, vileness or depravity in the private or social duties which a man [sic] owes to his fellow man [sic] or to society in general. The term implies something immoral in itself. ( Seary v State Bar of Texas 1980, cited in Freckelton 1996 : 142)

Moral delinquency, it will be recalled, refers to any act involving moral negligence or a dereliction of moral duty. As discussed in Chapter 1 , moral delinquency in professional contexts entails a deliberate or careless violation of agreed standards of ethical professional conduct.

Accepting the above definitions, an immoral nurse can thus be described as someone who knowingly and willfully violates the agreed norms of ethical professional conduct or general ethical standards of conduct towards others. Judging immoral conduct, by this view, would require a demonstration that the accepted ethical standards of the profession were both (1) known by an offending nurse, and (2) deliberately and recklessly violated by that nurse. There are many ‘obvious’ examples of immoral conduct by nurses. These include: the deliberate theft of patients’ and / or clients’ money for personal use; the sexual, verbal and physical abuse of patients / clients; xenophobic behaviours (including racism, sexism, ageism, homophobia and a range of other unjust discriminatory behaviours); participation in unscrupulous research practices; and other morally unacceptable behaviours, examples of which are given throughout this book.

It should be noted that, regardless of whether an act involving the violation of agreed professional or general ethical standards results in a significant moral harm to another, it would still stand as an instance of immoral or unethical conduct. For example, a nurse who knowingly and recklessly breaches a patient’s confidentiality would have committed an unethical act even if the breach in question did not result in any significant moral harm to the patient.

Moral complacency

An eighth type of moral problem nurses can encounter is that of ‘moral complacency’, defined by Unwin (1985 : 205) as ‘a general unwillingness to accept that one’s moral opinions may be mistaken’. It could also be described as a general unwillingness to ‘let go’ the primacy of one’s own point of view, or to regard one’s own point of view as just one of many to be compared, contrasted and considered. Again, we do not need to look far to find examples of moral complacency in health care contexts. Nurses and others who are ‘true believers’ in advance care planning in contexts where patients and their families have indicated they do not want to engage in such a process and do not accept the assumed value of such plans is an example ( Johnstone 2012b ; Johnstone & Kanitsaki 2009a ).

Like moral unpreparedness and moral blindness, moral complacency is something which can be remedied by moral education, moral consciousness raising and reflective practice in an ethical environment that has organisational support. The objective of taking this action would be to produce in the morally complacent person the attitude that nobody can afford to be complacent in the way he or she ordinarily views the world – least of all the moral world. This is particularly so in instances where other people’s moral interests are at stake. It is a ‘thinking error’ and also arrogant to assume that our moral opinions are ‘right’ just because they are our own opinions.

As ethical professionals, our stringent moral responsibility is to question our taken-for-granted assumptions about the world – and about bioethics discourse generally – and not to presume that they are always well founded and unable to be challenged. It also requires going beyond mere values clarification and embracing what Garrett (2014 : 1) refers to as ‘two more ambitious agendas’ for bioethical thinking. The first of these agendas involves ‘critique, unmasking, interrogating and challenging the presuppositions that underlie bioethical discourse’; the second agenda involves ‘integration’ and adopting a transcendent stance which encompasses ‘honoring and unifying what is right in competing values’ ( Garrett 2014 : 1).

Moral dumbfounding / stupefaction

The ninth problem to be considered here is that of ‘moral dumbfounding’ – also called ‘moral stupefaction’. Although there is no single agreed definition of moral dumbfounding, it is generally held to occur when people stubbornly maintain a moral judgment despite not having reasons to either support or defend the judgments they have made ( McHugh et al 2017 ). When pressed to supply reasons for their stance, people typically become ‘dumbfounded’ or ‘stupefied’ (left with a ‘mental blank’) and resort to making unsupported declarations such as ‘It is just wrong’ as a justification ( McHugh et al 2017 ). Examples classically used in the literature are generally taken from Haidt’s foundational work ( Haidt 2001 ; Haidt et al 2000 ) on the subject and include acts such as (i) consensual protected sex between adult siblings; (ii) cannibalism of a body that is already dead and soon to be incinerated; and (iii) eating one’s pet dog after it has just died from an accident. When asked about their views on these and similar examples, research participants typically declare that the acts in question ‘are wrong’. When pressed to ultimately provide sound reasons and justifications for their negative verdicts on these examples, participants have tended to become ‘dumbfounded’ admitting either that ‘they don’t know’, ‘they can’t explain’, or that it (incest, cannibalism, eating your pet) is ‘just wrong’ (seemingly based on a misattribution of these acts being harmful) – or ‘just disgusting’ (an emotional response) ( Haidt 2001 ; Haidt & Björklund 2008 ; Haidt et al 2000 ; Hindriks 2015 ; McHugh et al 2017 ).

Not all agree that the phenomenon of moral dumbfounding / stupefaction exists and to date it remains the subject of controversy. Gray and colleagues (2014 : 1600), for example, contend that ‘perceiving harm in immorality is intuitive and does not require effortful rationalization’. This accounts for why people are not always able to provide reasons for their negative verdicts of perceived morally harmful acts – that is, their ‘reasons’ are normative moral intuitions which cannot be rationalised.

Royzman and colleagues (2015) , meanwhile, contend that where the thesis fails is the assumption that the acts in question are ‘harmless’. They argue that research participants may have ‘excellent reasons’ to disapprove of the acts – that is, they may not believe that incest, cannibalism, and eating your pet are ‘truly’ harmless and, accordingly, that they are indeed ‘wrong’; they may later recant their previous ‘dumbfounding’ statements and give a reason; and once the cultural standards of normative evaluation are factored in their responses are, all things considered, ‘reasonable’ ( Royzman et al 2015 ).

A search of the literature has found that, apart from works addressing intuitionism in nursing, the existence, relevance and possible implications of moral dumbfounding / stupefaction in nursing and health care contexts have not yet been considered. This stands as an area that would benefit from future inquiry.

Moral fanaticism

A tenth type of moral problem which may be encountered by nurses, and which is similar in many respects to moral complacency, is that of ‘moral fanaticism’. The moral fanatic is someone who is thoroughly ‘wedded to certain ideals’ and uncritically and unreflectingly makes moral judgments according to them ( Hare 1981 : 170). Richard Hare’s classic case of the fanatical Nazi is a good example here ( Hare 1963 : Chapter 9 ). The fanatical Nazi in this case stringently clings to the ideal of a pure Aryan German race and the need to exterminate all Jews as a means of purging the German race of its impurities. The Nazi falls into the category of being a ‘fanatic’ when he / she insists that, if any Nazis discover themselves to be of Jewish descent, then they too should be exterminated along with the rest of the Jews ( Hare 1963 : 161–2).

Examples of moral fanaticism exist in health care contexts. The maintenance of absolute confidentiality, even though harm might be caused as a result, is an example. So, too, is the example of a doctor or a nurse forcing unwanted information on a patient in the fanatical belief that all patients ‘ must be told the truth’ – even if the patient in question has specifically requested not to receive the information, and the imposition of the unwanted information on the patient can be shown to be a ‘gratuitous and harmful misinterpretation of the moral foundations for respect for autonomy’ ( Pellegrino 1992 : 1735).

In the case of moral fanatics, an appeal to overriding considerations or principles of conduct would not be helpful ( Hare 1981 : 178). As with the amoralist, the problem of the moral fanatic in health care contexts is likely to have disappointing outcomes. In the final analysis, it may be that other (non-moral) mechanisms will have to be appealed to in order to resolve the moral problems caused by moral fanaticism; for example, it may be necessary to seek the involvement of a public advocate, a court of law or a disciplinary body to arbitrate the matter.

Moral disagreements

An eleventh type of moral problem nurses will very often encounter is that involving ‘moral disagreement’ – concerning, for example, the selection, interpretation, application and evaluation of moral standards. In his classic article ‘Moral deadlock’, Milo (1986) identifies two fundamental types of moral disagreement: internal moral disagreement and radical moral disagreement.

Moral conflict

The twelfth type of problem to be considered here is that of a ‘moral conflict’. Moral conflict (to be distinguished from conflicting principles and obligations that underpin moral dilemmas, as discussed above) fundamentally involves a clash of opposing ideas and interests of different agents (e.g. members of the health care team, family members and the like). In several respects, moral conflict is the logical extension of intractable moral disagreement. Matters commonly identified as being the source of moral conflicts are: goals of patient care and treatments, quality of care, preventing and alleviating patient suffering, poor communication, and resource allocation ( Edelstein et al 2009 ; Gaudine et al 2011 ; Leuter et al 2017 ; Pavlish et al 2013 , 2014 ). Conflicts can manifest as contentious moral arguments, emotional outbursts and other disruptive behaviours ( Danjoux et al 2009 ; Pavlish et al 2014 ). Unresolved they can have a significant negative impact on relationships, patient care and the culture of the organisations – specifically they can weaken an organisation’s ethical climate ( Pavlish et al 2013 ).

It is difficult to assess the incidence and impact of moral conflict in nursing domains. One reason for this is that it has not been comprehensively studied. Instead the problem of moral conflict has tended controversially to be positioned as the ‘cause’ of moral distress in nursing, with attention focusing more on the nature and impact of ‘moral distress’ than on moral conflict per se. What has been misunderstood by those who have conflated the issue of moral conflict and moral distress is that, whereas moral distress concerns conflict within oneself , moral conflict concerns conflict with others . The problem of moral conflict is considered further in Chapter 11 of this text.

Moral dilemmas

Another significant moral problem (the thirteenth) to be considered here (and one which has been widely discussed in both nursing and bioethical literature) is that of the proverbial ‘moral dilemma’ (also called ‘ethical dilemma’). Broadly speaking, a dilemma may be defined as a situation requiring choice between what seem to be two equally desirable or undesirable alternatives; it may also be described as an ‘awful feeling of being stuck’. A moral dilemma, however, is a little different, and can occur in one of several forms.

First, a moral dilemma can occur in the form of logical incompatibility between two different moral principles. For example, two different moral principles might apply equally in a given situation, and neither principle can be chosen without violating the other. Even so, a choice has to be made. Consider the case of a nurse who accepts a moral principle which demands respect for the sanctity of life, and who also accepts another moral principle (non-maleficence) which demands that persons should be spared the harm of intolerable suffering. In the context of caring for a patient with intractable pain, it may not be possible to uphold both principles where, for example, a medical prescription for palliative sedation has been prescribed (the issue of palliative sedation is discussed in Chapter 10 of this book). The ultimate question posed for the nurse in this situation is: Which principle should I choose? The options open to the nurse are:

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  to modify the principles in question so that they do not conflict (i.e. by adding ‘riders’ to them)

  
  
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  to abandon one principle in favour of the other

  
  
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  to abandon both principles in favour of a third (e.g. autonomy and respect for the patient’s wishes).

A second type of moral dilemma is that involving competing moral duties . Consider the following case. A nurse working in a specialised unit is assigned a patient with a known history of drug addiction, and is instructed to chaperone the patient when there are visitors to make sure that illicit drugs are not ‘slipped in’. The nurse, however, believes that the duty to protect this patient from harm (such as might occur from receiving illicit drugs) competes with the duty to respect the patient’s privacy. The question for the nurse in this scenario is: Which duty should I fulfil?

In another case, a nurse is assigned a patient of traditional Greek background who has recently been diagnosed with metastatic cancer. The doctor has ordered that the patient not be told his diagnosis. The patient, however, keeps asking the nurse and his family for information about his diagnosis. The family knows the diagnosis, but wants the doctor to tell the patient. Here the nurse is caught between a duty to tell the truth to the patient, and a duty to respect the wishes of the family. The nurse is also obliged to follow the doctor’s directives. The question for the nurse in this scenario is, again: Which duty should I fulfil – my duty to the patient, or to the family, or to the doctor, or to whom?

Philosophical answers to questions raised by a conflict of duty are varied and controversial. In the classic work The right and the good , Ross (1930) argues that duties are prima facie or ‘conditional’ in nature. Thus, when two duties conflict, we must ‘study the situation’ as fully as we can until we are able to reach a ‘considered opinion (it is never more) that in the circumstances one of them [the duties] is more incumbent than any other’ ( Ross 1930 : 19). Once we have worked out which of the conflicting duties is the more ‘incumbent’ on us, we are bound to consider it our prima-facie duty in that situation. Richard Hare (1981 : 26), however, takes a different view. He argues that, if we find ourselves caught between what appear to be two conflicting duties, we need to look again. For it is likely that, in the case of an apparent conflict in duties, one of our so-called ‘duties’ is not our duty at all; we have only mistakenly thought that it was. In other words, what happens here is that one of the two apparently conflicting duties is eventually ‘cancelled out’.

Williams (1973) disagrees. While he believes that one of the conflicting duties has to be rejected (but only in the sense that both conflicting duties / oughts cannot be acted upon), he does not agree that this means that the duties or oughts in question do not apply equally in the situation at hand, or that one of the conflicting duties must inevitably be ‘cancelled out’. To the contrary: our reasoning may assist us to deal with a conflict of duty and may assist us to find a ‘best’ way to act, but this does not mean that we abandon one or other of the duties in question. How do we know? Even after making a choice between two conflicting duties, we are still left with a lingering feeling of ‘regret’. And it is this very feeling of regret which tells us that we have not altogether abandoned or ‘cancelled out’ the duty we decided could not, in that situation, be also acted upon.

In the drug addict case, we might well side with Richard Hare and unanimously agree that the nurse is mistaken in a belief that there is an overriding duty to respect the patient’s privacy, and that clearly the primary duty is to prevent the patient from suffering the harms likely to be incurred by the administration of illicit drugs. But here the question arises: Is it really a nurse’s duty to act as a kind of police warden? What if the patient is not receiving any form of therapy for the immediate drug addiction problem, and is at risk of developing severe and life-threatening withdrawal symptoms? How is the nurse’s duty to ‘prevent harm’ to be regarded in this instance? Does cancelling out one of the conflicting duties here relieve the moral tension created in this scenario? Or is there more to be achieved by exploring ways in which they can be reconciled with each other?

In the cancer diagnosis case, it might be unanimously agreed that the nurse’s primary duty is to the patient, and that any apparent duty owed to the family is not a bona fide one. Placed in a cultural context, however, the scenario takes on a whole new dimension. As was considered in Chapter 4 of this book, families from a traditional cultural background often play a fundamental and highly protective role in mediating the flow of information to a sick loved one. To ignore a family’s request in such a situation could be to risk a violation of the wellbeing of the patient. Where this is likely, it is imperative that the nurse works closely with the family and ensures that the transfer of information to the patient is handled in a culturally appropriate manner . While the family may be perceived as ‘interfering’, in reality it may be providing an important link in ensuring that the patient’s wellbeing and moral interests are fully upheld.

Cancelling out one of the duties in this scenario is unlikely to relieve the moral tension generated by the patient’s request for and the doctor’s refusal to give the medical information on the patient’s diagnosis. Had the only criterion for action been what superficially appeared to be a primary duty to the patient, the nurse may have unwittingly facilitated the flow of information in a culturally inappropriate and thus harmful manner. By reconciling the apparent conflict in duties, and by working closely with the family, however, the nurse is able to facilitate the flow of information to the patient in a culturally appropriate and thus less harmful manner. In this instance, by fulfilling the duty owed to the family, the nurse could also succeed in fulfilling the duty owed to the patient.

It might be objected that the examples given here do not involve difficult cases, and that the required choices are relatively easy to make. But even if we admit ‘hard cases’, Hare’s position is somehow unsatisfactory, as is his argument that when there is an apparent conflict in duties it is likely that one of the duties involved is not our duty at all. There is always room to question how we can ever be really sure that a ‘cancelled’ duty was not our duty in the first place. The cancer diagnosis case, I think, illustrates this point well. Ross’s (1930) and Williams’ (1973) positions, on the other hand, remind us that matters of moral duty are never clear-cut and, further, that we always have to be careful in our appraisal of given situations and in the choices we make regarding to whom our moral duties are owed and what our moral duties actually are.

A third kind of moral dilemma, and one closely related to a dilemma concerning competing duties, is that entailing competing and conflicting interests . Here the question raised for the moral observer is: Whose interests ought I to uphold?

Consider the following case. A clinical teacher on clinical placement at a residential care home is informed by a student that an elderly demented resident has been physically and verbally abused by one of the ward’s permanent staff members, as witnessed by the student. The clinical teacher is temporarily undecided about what to do. It is a very serious matter – and, indeed, a very serious accusation – but it will be difficult to prove. If the incident is not reported to the home’s nursing administrator, the staff member concerned will probably continue to abuse the home’s residents. If the incident is reported, there is a risk that the interests of both students and the school of nursing could be undermined. (The home’s administrator might, for example, refuse to continue allowing students to be placed at the home for the purposes of gaining clinical experience.) The dilemma for the clinical teacher is whether to not report the matter and thereby protect both the students’ and the school’s interests in having continued clinical placements, or to report the matter fully, whatever the consequences to the school and the students, and thereby protect the residents’ interests.

The teacher and the student mutually agree that the matter is too serious to ignore and decide they would risk the consequences of reporting the incident. The exercise, as feared, proves extremely distressing and painful for both the student concerned and the clinical teacher. The accused staff member denies having abused the elderly resident, and in turn accuses the student of lying and of being the one who has really committed the abuses. The opinion of the patient cannot be sought, as the elderly resident concerned is suffering from advanced dementia. Fortunately, the matter is eventually resolved to everyone’s satisfaction. The administrator takes the allegation seriously and, later, takes the initiative to emphasise to all staff the importance of protecting and upholding residents’ rights. The student is reassured that she has done the ‘right thing’, and that she has fulfilled her professional and moral obligations both (1) in reporting the incident and (2) in the manner in which she had reported it (i.e. she has followed proper processes). The clinical supervisor and administrator reach an agreement that any matters of concern discussed during clinical teaching placements be referred directly and immediately to the administrator for action. The staff member who was the subject of the unsubstantiated allegation is counselled in confidence by the administrator.

A fourth type of dilemma is taken from a feminist moral perspective, and is described by Gilligan (1982) in terms of being caught between attachments to people and trying to decide upon ways that will avoid ‘hurting’ each of these ‘attached people’. Gilligan uses the example of a woman contemplating an abortion; she argues that generally a woman faced with having to make a choice in this situation ‘contemplates a decision that affects both self and others and engages directly the critical moral issue of hurting’ ( Gilligan 1982 : 71). Here the question to be raised in contemplating a difficult choice is: How can I avoid hurting the people to whom I am attached?

It might be objected here that Gilligan’s sense of ‘hurt’ and ‘avoiding hurt’ is not very different from the general moral principle of non-maleficence and its demand to avoid or prevent ‘harm’. While it might be conceded that ‘hurt’ is a type of harm, there is a subtle distinction between ‘hurt’ in the sense that Gilligan seems to be using it and ‘harm’ in an abstract sense as used by philosophers. It is important to draw a distinction between these two notions so as not to obscure other important distinctions which can be drawn in moral discourse. Let us examine this point a little more fully.

The sense in which ‘hurt’ is being used here is not simply ‘physical’, but rather existential. There is even room to make the radical claim that the notion of ‘avoiding hurt’ is not being asserted as a principle as such, but more as an attitude , and one which reminds us that we need to take very special care in our selection, interpretation and application of general moral principles in our everyday personal and professional lives. In short, it is an attitude which serves to mediate the use of more general moral principles. Consider, for example, the demand to ‘avoid hurt’ in a situation involving a patient who has yet to be told an unfavourable medical diagnosis. The demand to ‘avoid hurt’ reminds us that it is not enough just to give the patient the diagnosis (as may otherwise be required by the moral principle of autonomy), but that it must also be given in a caring, compassionate and culturally appropriate manner. Furthermore, it is not clear that, in this instance, the principle of non-maleficence fully captures the demand to be caring, compassionate and culturally appropriate in manner when performing such an unpleasant task as giving someone an unfavourable medical diagnosis. And in some instances, taken to its extreme, the principle of non-maleficence might even instruct that the diagnosis should not be given at all. ‘Avoiding hurt’, on the other hand, recognises that the information that needs to be given could be ‘harmful’ and is probably ‘hurtful’, but that there is a way of lessening if not avoiding this harm and hurt. To illustrate this point, consider the following case.

A newly graduated doctor walks into a patient’s room, stands at the end of the bed and, in full view and hearing distance of other patients in the room and without greeting the patient or smiling, states abruptly: ‘We’ve looked at your throat and the lump you have there is cancer.’ Without another word, the doctor then briskly walks off. The patient has previously expressed a desire to know the diagnosis when it was available, so in several respects it could be concluded that the doctor acted ‘ethically’ in that the patient’s wishes have been respected and the requested information has been relayed to the patient. What is evident in this case is that the doctor has not considered ways to give the information less ‘hurtfully’ – or, if such ways have been considered, they were not heeded. For example, the doctor might have at least greeted the patient, used a compassionate tone of voice, drawn the curtains around the patient before speaking, sat down on a chair to be at the same level as the patient, and stayed long enough to allow the patient to ask questions, which the patient later confides she wanted to do. If the doctor felt inadequate to deal with this situation, it would have been advisable to wait until a medical colleague or a nurse was available to accompany him. Or, more simply, the doctor should have deferred to someone else who was more experienced and better prepared to deal with the situation. By using such an abrupt manner, the doctor not only failed to ‘avoid hurt’, but exacerbated it.

Nurses have likewise failed to avoid or to lessen the hurt of a given situation. An example of this can be found in the tragic case of a middle-aged man who was dying from advanced cancer. A close friend and members of his family were greatly distressed about his deteriorating condition, and even accused the nursing staff of ‘trying to kill’ their loved one by giving him morphine for his pain. On one occasion the nursing staff observed the family friend clutching his friend and pleading with him not to accept the morphine injections, telling him: ‘Don’t you see, they are killing you! They are killing you! You don’t have to have them …’ The nursing staff tried to get the friend to leave, but he refused to go. When he became abusive, the nursing staff contacted a hospital security officer, and he was forcibly removed. There is room to speculate about this case: had the friend’s behaviour been recognised as a grief response (which it was), had his grief been properly addressed by the nursing staff, and had the dynamics and benefits of effective pain management been fully explained to him, then he, the patient, the patient’s family and the attending nursing staff would have been spared the ‘hurt’ that this awful situation caused.

These two cases demonstrate that ‘avoiding hurt’ is not something that can be fully directed or achieved by an abstract moral principle. Rather, it requires that we draw on our past experience, knowledge, intuition, awareness, insight, feelings and interpersonal skills, as well as on a thorough and systematic analysis of the facts of the situation at hand.

‘Moral distress’ ¹

The fourteenth and final type of moral problem to be considered here is that of ‘moral distress’. During the course of their day-to-day practice, nurses will invariably encounter situations in which they may be required to make a moral decision. In some instances, despite deciding what they believe is the ‘right thing to do’, nurses may nonetheless feel constrained in acting on their moral judgments and, in the end, either do nothing or do what they believe is the wrong thing to do ( Jameton 1984 ). This situation has been hypothesised in the nursing ethics literature as giving rise to what has been controversially termed ‘moral distress’.

The notion of moral distress dates back to the foundational work of US philosopher Andrew Jameton and may take one of two forms:

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  initial moral distress , which is characterised by feelings of frustration, anger, anxiety and guilt when faced with perceived institutional obstacles and interpersonal conflict about values, and

  
  
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  reactive moral distress (also called moral residue ), which occurs when an individual fails to act on their initial moral distress and is left with ‘residue’ or lingering distress ( Jameton, 1984 , Jameton, 1993 ; see also Epstein & Hamric 2009 ).

The ‘root cause’ of moral distress in nursing has been attributed to three key domains: clinical situations (e.g. controversial end-of-life decisions; inadequate informed consent; working with incompetent practitioners); internal constraints (e.g. nurses’ lack of moral competencies; perceived lack of autonomy and powerlessness to act; lack of knowledge and understanding of the full situation); and external constraints (e.g. hierarchies within the health care system; inadequate communication among team members; hospital policies and priorities that conflict with patient care needs) ( Hamric et al 2012 ). Of these domains, clinical situations involving ‘prolonged, aggressive treatment that the professional believes is unlikely to have a positive outcome’ are regarded as being the most common cause of moral distress in nurses ( Epstein & Hamric 2009 : 2).

In recent years, moral distress has been portrayed as a ‘major problem in the nursing profession, affecting nurses in all health care systems’ ( Corley 2002 : 636; see also Musto & Rodney 2018 ). ² It is depicted as threatening the integrity of nurses and, in turn, the quality of patient care. It has also been implicated in the problem of nurse retention, with some scholars suggesting that unresolved moral distress can lead to nurses experiencing job dissatisfaction, burnout, and ultimately abandoning their positions and even their profession altogether. More recently, it has been cited as ‘the cause’ of moral disengagement by nurses ( Hyatt 2017 ). Even so, as Johnstone and Hutchinson (2015) argue, the notion of moral distress is not without controversy and may even be misguided. Moreover, without further inquiry into the psychological underpinnings and ethical components of nurses’ responses to moral issues in the workplace, there is a risk that continuing nursing narratives on ‘moral distress’ might serve more to confuse rather than clarify the ethical dimensions and challenges of nursing work.

Linchpin to the theory of moral distress is the idea that ‘nurses know what is the right thing to do, but are unable to carry it out’. This idea is highly questionable, however, since it assumes without supporting evidence the unequivocal correctness of nurses’ moral judgments in given situations. It also underestimates the capacity of nurses to take remedial action even in difficult environments ( Johnstone & Hutchinson 2015 ).

Research has shown that different people can make quite different yet equally valid moral judgments about the same situation. Even when presented with ‘the facts’, decision-makers rarely change their minds (see also moral dumbfounding / stupefaction, discussed as problem nine in this section). Instead they will search for and accept only information that reaffirms their initial intuitions ( Sonenshein 2007 ). One reason for this is that people approach situations with their own individual system of ethics and a predetermined stance on what they value and believe is right and wrong. In keeping with their own ‘bounded personal ethics’ individuals will construct, interpret and respond to issues ‘based on their own personal motivations and expectations’ ( Sonenshein 2007 : 1026) as well as past behaviours including ‘blind spots’ that have obscured their previous moral failures ( Chugh & Kern 2016 ).

Nurses are no exception in this regard. Even in contexts plagued by uncertainty and complexity (of which clinical environments are a prime example) nurses are just as vulnerable as are others to constructing idiosyncratic ‘subjective interpretations of issues beyond their objective features’ ( Sonenshein 2007 : 1026). It is thus inevitable that they will encounter moral disagreements in the workplace and that some of these disagreements might engender an intense emotional reaction.

Essential to the theory of moral distress is the assumption that such a state in fact exists. Much of what has been written about moral distress, however, involves little more than an appropriation of ‘ordinary’ psychological and emotional reactions (e.g. frustration, anger) that nurses may justifiably feel when encountering moral issues and disagreements in the workplace. Whether these reactions necessarily constitute ‘moral distress’, however, is another matter.

Research ostensibly identifying nurses’ moral distress and exploring its incidence and impact in the workplace is also problematic. First, the scenarios used in survey research instruments (see Corley 2002 ) tend to depict situations that lack equivocality and uncertainty than is likely in the clinical settings in which nurses’ work. These instruments thus minimise the role of ‘issues construction’ by nurses and erroneously frame the scenarios as involving a clear choice between right and wrong (see Jones 1991 ). Second, the very presentation of given issues in the moral distress scales used by researchers already pre-code and interpret the situations presented as involving ‘moral distress’ thus priming respondents to accept both the existence and incidence of moral distress as a ‘reality’ in their practice.

In order to better understand the foundations of moral disagreements in the workplace and nurses’ reactions to them, more needs to be known about nurses’ taxonomy of ethical ideologies – that is, what their personal ethical standpoints are, the extent to which their personal views frame their ethical decision-making and behaviours in professional contexts, and the bases upon which they justify their conduct. Until further inquiries are made, the assumed credibility of ‘moral distress’ as a bona fide problem in nursing will remain dubious.