© Springer International Publishing AG 2017P. Anne Scott (ed.)Key Concepts and Issues in Nursing Ethics10.1007/978-3-319-49250-6_4
4. Virtue Ethics and Nursing Practice
Faculty of Nursing, University of Alberta, Edmonton, T6G 1C9, Canada
Virtue ethics is an approach that focuses on character with the assumption that a person of good character will tend to behave in ways that are consistent with their character. A virtue ethics for nursing is therefore concerned with the character of individual nurses and seeks ways to enable nurses to develop character traits appropriate for actions that enhance wellbeing. This chapter offers some insights into the nature of virtue ethics from an Aristotelian perspective and includes an outline of the virtue of phronesis (practical wisdom) which provides guidance in situations where it is not obvious what action would be the virtuous action. Virtue ethics is contrasted with modern ethical theory (deontology and utilitarianism) and some ways in which virtue ethics can enhance professional nursing practice are considered.
KeywordsVirtueAristotleKindnessCompassionPhronesis (Practical Wisdom)Nursing
This chapter is about the idea of virtue ethics. In recent times virtue ethics has come to be considered as one of the big three ethical approaches alongside deontology and utilitarianism. However, virtue ethics has made fewer inroads into applied and professional ethics because “… unlike deontological theories or consequentialist theories, virtue theory is not geared toward answering specific questions, or making specific ethical decisions” (Lachman 2006 p. 10). If this is true then it might be reasonable to ask what it is that virtue ethics can offer nurses as they go about their everyday practice. The short answer is that, at a minimum, virtue ethics can help to redirect focus away from mere rule following towards consideration of what counts as good for human beings. It does so by encouraging the cultivation of those character traits that promote actions that are fair, honest, kind, compassionate and so on; actions that contribute to human wellbeing. Thus, virtue ethics might be described as an approach that preempts the specific questions and specific decisions to which Lachman (2006) refers.
At the outset we should recognise that virtue ethics is not one thing but rather can be understood as an umbrella term for sets of ideas that share a common foundation. In this respect virtue ethics does not differ from other ethical approaches including but not limited to deontology and utilitarianism; there are factions in both of those theories that diverge in regards to particular points and interpretations. Nevertheless, as is commonly understood, there are some fundamental premises that underpin different versions of both deontology and utilitarianism, and the same can be said for virtue ethics. If the deontologist is characterised as claiming that an act is good if it is in accordance with duty and the utilitarian is characterised as claiming that an act is good if it brings about the best consequences, then the virtue ethicist might be characterised as claiming that an act is good if it is a virtuous act. These characterisations are, of course, over-simplifications and while it is not the purpose of this chapter to discuss deontology or utilitarianism,1 both theories will be mentioned in order to help explain some of the nuances of virtue ethics and how it differs from those two theoretical approaches. The essential point here is that just as there are different versions of deontology and utilitarianism, so there are different versions of virtue ethics.
The one thing that underpins virtue ethics is the emphasis on character; and this focus on the character of the agent is what distinguishes virtue ethics from most other approaches to ethics.2 Some versions of virtue ethics characterise this difference as a difference of the primary question: so that whereas most ethical theories seeks to answer the question ‘what should I do?’ virtue ethics asks instead ‘what type of person should I be?’ This distinction suggests either that what a person does is less important than how a person is, or that virtue ethics does not provide action guidance. Neither suggestion is as straightforward as critics claim, and, as will be outlined in this chapter, both oversimplify many of the ideas about virtue ethics. Danielle’s experience, described in the case-study below, is illustrative and will be referred to throughout the remainder of this chapter in order to explore some key elements of virtue ethics.
Danielle is a third-year student nurse half-way through her final clinical placement on Azalea ward, a busy surgical unit. Like all student nurses she has had a mentor in each of her previous placements but she has never before met anyone quite like Belanna, her mentor on Azalea ward. It is a very busy ward, yet unlike most of the other qualified nurses Danielle has worked with, Belanna seems always to know what to do whatever the situation. She always has a kind word to say to everyone from the most difficult and demanding patient to the most arrogant and obnoxious of doctors; from the ward cleaner to the hospital chief executive, and even in the most challenging of situations she always seems to be able to find a way to ensure that everyone’s dignity is upheld, that no one gets left unattended, and that no one feels neglected or humiliated. Belanna is kind, compassionate, and caring but does not flinch from confronting situations that might otherwise undermine those ideals of practice. Yet she has no pretentions and does not think that what she does is anything special, in fact she thinks that she does not do anything different from that which anyone in her position would do. She is always seeking feedback from students, patients, families, and co-workers and goes out of her way to ensure that everyone who arrives on Azalea ward has a positive experience. At first Danielle thought that this was too good to be true, or that it was all an act that would collapse at the first sign of frustration but after 6 weeks on the placement, Danielle recognises that there is something about Belanna that marks her out as a particularly good nurse. Danielle decides that Belanna represents the type of nurse that she (Danielle) wants to become.
What Is Virtue Ethics?
So what is virtue ethics? Virtue ethics is the term given to an approach that has a focus on character. More specifically, it focuses on the character of the actor or agent. Hence virtue ethics is sometimes referred to as agent-based ethics. This is to be contrasted with act-based ethics in which the primary focus is on the act. As noted earlier, act-based ethics asks the question: ‘what should I do?’ while agent-based ethics tends towards asking: ‘what sort of person should I be?’ – although it should be noted that not all versions of virtue ethics make this distinction. Armstrong (2007), for example, claims an action-oriented account of virtue ethics for nursing while Crisp (2007) and Hursthouse (1997) both hint that the latter question is subsumed within the former and so engage seamlessly with action guidance in their accounts. A more nuanced distinction might be had by noting that act-based theories tend towards accounts in which action is in accordance with an external principle or from a rule derived from a general principle, while agent-based approaches tend to emphasize the role of character in formulating decisions for actions. So the deontologist may ask, ‘which duty takes precedence in this situation?’; the utilitarian may ask ‘what action will lead to the best consequence?’ and the principlist may ask ‘which principle applies here?’ In contrast, guidance for action in agent-based ethics requires the agent to seek to become a certain sort of person, a person with the virtues to lead them to act in ways that the virtuous person would act. So, following Hursthouse (1997), the virtue ethicist might ask ‘if I act in such and such a way, would I be acting in a way that was virtuous?’ The assumption here is that by becoming, for example, a just, courageous, and honest person, the individual will tend towards acting in just, courageous, and honest ways out of habit or inclination. This is to say that the just, courageous, and honest person will act in ways that reflect their character. And this is exactly what Danielle is witnessing when she sees her mentor (Belanna) in action. The reason Belanna seems to know what to do whatever the situation is that she is a kind, compassionate, honest, just, and courageous person and this is exemplified in her actions. Belanna acts in ways that reflect her character.
It is often said that people act characteristically. That is, we expect people to act in ways consistent with the type of person we take them to be. We tend to identify friends, colleagues, and peers in terms of their characteristics. We all know people who we can describe as kind or honest or courageous and the more they continue to act in ways that are kind and honest and courageous the more we appreciate and admire their integrity and their character. Similarly, most of us can identify individuals who might be described in more negative terms; we might thus identify some people as tending towards dishonesty, ruthlessness, unhelpfulness, unreliability and so on. Many of Danielle’s earlier mentors, while not particularly dishonest or unkind, did not seem to possess the same confidence in being the type of nurse who acts, as Belanna does, by inclination in kind or honest ways. Most of Danielle’s earlier mentors did aim to do the right thing but sometimes doing the right thing seemed to require them to follow rules or general guidance. Of course, general rules are helpful but at times merely following the rules seemed to result in nursing actions that might be perceived as, if not exactly unkind, then at least less than kind or less than compassionate. Danielle has a vivid recollection of the distress experienced by a young patient when informed of the death of her husband in the car accident in which they had both been involved. Danielle has often wondered if being told the truth in the matter-of-fact manner in which the news was delivered was a kind thing to do, but she had been told that being honest was a requirement of both the nurses code (NMC 2015) and of the principle of respect for autonomy (justified on the grounds that a patient has a right to know the truth if they are to make autonomous choices). Having now seen the way in which Belanna is honest in her dealings with patients, relatives, and others while at the same time being compassionate and kind is leading Danielle to question whether what she has been told previously about ethical practice is altogether accurate or satisfactory. Danielle is now beginning to recognise that being honest is only one part of ethics. The need to act in ways that are not callous or unkind means that honesty cannot be seen in isolation from other aspects of ethical nursing practice. And the more she watches Belanna’s practice, the more Danielle wants to be like her, and the more she recognises that Belanna acts characteristically in kind, honest, compassionate, fair, and courageous ways; that is, in ways that reflect the type of person, the type of nurse, that Belanna is.
That we can make such judgements indicates that we acknowledge the idea of character, which lends weight to the idea of virtue ethics, because in virtue ethics character guides conduct. In other words, virtue ethicists will want to say that right action follows right character. And it is this primacy of character that distinguishes virtue ethics from other approaches to ethics. In our case-study, Belanna seems to represent a nurse with the virtues insofar as her actions appear to stem from her character traits. She acts in kind ways because she is a kind person; she acts in honest ways because she is an honest person, and so on.
From the basic tenet of virtue ethics – that individuals generally act in ways consistent with their character traits – it follows that those who wish to act in virtuous ways should seek to become virtuous persons. In so doing the question ‘what should I do?’ becomes one that is asked less often because in many situations, just as Belanna exemplifies, what a person should do is what they characteristically would do. But perhaps this language of virtues is off-putting or old-fashioned. Perhaps a change of language might be useful. So instead of a phrase such as ‘virtue ethics requires those who wish to act in virtuous ways to become virtuous persons’ we might say instead ‘virtue ethics requires that those who wish to act for the good need to develop good traits of character’. The virtues of kindness, honesty, courage, and justice are perhaps better understood in modern vocabulary as character traits. And most people identify these as positive traits; traits that are admired and identified as good things in and of themselves; traits that are encouraged in society in general and in nursing (and other health care occupations) in particular (see for example, the NMC (2015) code for nurses).