Furthering the sceptical case against virtue ethics in nursing ethics

In a recent article in this journal I presented a sceptical argument about the current prominence of virtue ethics in nursing ethics. Daniel Putman has responded with a defence of the relevance of virtue in nursing. The present article continues this discussion by clarifying, defending, and expanding the sceptical argument. I start by emphasizing some features of the sceptical case, including assumptions about the nature of sceptical arguments, and about the character of both virtue ethics and nursing ethics. Then I respond to objections of Putman's such as that, according to virtue ethics, virtue is relevant to the whole of a human life, including one's behaviour in a professional context; and that eudaimonia should be central in explaining and motivating a nurse's decision to enter the profession. Having argued that these objections are not compelling, I go on to discuss an interesting recent attempt to reassert the role of virtue ethics in the ethics of professions, including nursing. This centres on whether role‐specific obligations – e.g. the obligations that arise for a moral agent qua lawyer or mother – can be accommodated in a virtue ethics approach. Sean Cordell has argued that the difficulty of accommodating role‐specific obligations results in an ‘institution‐shaped gap’ in virtue ethics. He suggests a way of meeting this difficulty that appeals to the ergon of institutions. I endorse the negative point that role‐specific obligations elude virtue ethics, but argue that the appeal to the ergon of institutions is unsuccessful. The upshot is further support for scepticism about the virtue ethics approach to nursing ethics. I end by gesturing to some of the advantages of a sceptical view of virtue ethics in nursing ethics.     

Towards a strong virtue ethics for nursing practice

Abstract  Illness creates a range of negative emotions in patients including anxiety, fear, powerlessness, and vulnerability. There is much debate on the 'therapeutic' or 'helping' nurse–patient relationship. However, despite the current agenda regarding patient-centred care, the literature concerning the development of good interpersonal responses and the view that a satisfactory nursing ethics should focus on persons and character traits rather than actions , nursing ethics is dominated by the traditional obligation, act-centred theories such as consequentialism and deontology. I critically examine these theories and the role of duty-based notions in both general ethics and nursing practice. Because of well-established flaws, I conclude that obligation-based moral theories are incomplete and inadequate for nursing practice. I examine the work of Hursthouse on virtue ethics' action guidance and the v-rules. I argue that the moral virtues and a strong (action-guiding) version of virtue ethics provide a plausible and viable alternative for nursing practice. I develop an account of a virtue-based helping relationship and a virtue-based approach to nursing. The latter is characterized by three features: (1) exercising the moral virtues such as compassion; (2) using judgement; and (3) using moral wisdom, understood to include at least moral perception, moral sensitivity, and moral imagination. Merits and problems of the virtue-based approach are examined. I relate the work of MacIntyre to nursing and I conceive nursing as a practice: nurses who exercise the virtues and seek the internal goods help to sustain the practice of nursing and thus prevent the marginalization of the virtues. The strong practice-based version of virtue ethics proposed is context-dependent, particularist, and relational. Several areas for future philosophical inquiry and empirical nursing research are suggested to develop this account yet further.     

How should a nurse approach truth‐telling? A virtue ethics perspective

Abstract Truth‐telling is a key issue within the nurse–patient relationship. Nurses make decisions on a daily basis regarding what information to tell patients. This paper analyses truth‐telling within an end of life scenario. Virtue ethics provides a useful philosophical approach for exploring decisions on information disclosure in more detail. Virtue ethics allows appropriate examination of the moral character of the nurse involved, their intention, ability to use wisdom and judgement when making decisions and the virtue of truth‐telling. It is appropriate to discuss nursing as a ‘practice’ in relation to virtue ethics. This is achieved through consideration of the implications of arguments made by Alasdair MacIntyre who believes that qualities such as honesty, courage and justice are virtues because they enable us to achieve the internal goods of practices.     

The metaethics of nursing codes of ethics and conduct

Nursing codes of ethics and conduct are features of professional practice across the world, and in the UK, the regulator has recently consulted on and published a new code. Initially part of a professionalising agenda, nursing codes have recently come to represent a managerialist and disciplinary agenda and nursing can no longer be regarded as a self‐regulating profession. This paper argues that codes of ethics and codes of conduct are significantly different in form and function similar to the difference between ethics and law in everyday life. Some codes successfully integrate these two functions within the same document, while others, principally the UK Code, conflate them resulting in an ambiguous document unable to fulfil its functions effectively. The paper analyses the differences between ethical‐codes and conduct‐codes by discussing titles, authorship, level, scope for disagreement, consequences of transgression, language and finally and possibly most importantly agent‐centeredness. It is argued that conduct‐codes cannot require nurses to be compassionate because compassion involves an emotional response. The concept of kindness provides a plausible alternative for conduct‐codes as it is possible to understand it solely in terms of acts. But if kindness is required in conduct‐codes, investigation and possible censure follows from its absence. Using examples it is argued that there are at last five possible accounts of the absence of kindness. As well as being potentially problematic for disciplinary panels, difficulty in understanding the features of blameworthy absence of kindness may challenge UK nurses who, following a recently introduced revalidation procedure, are required to reflect on their practice in relation to The Code. It is concluded that closer attention to metaethical concerns by code writers will better support the functions of their issuing organisations.     

Open-mindedness: a virtue for professional practice

Abstract   This paper introduces the notion of open-mindedness before proceeding to outline its value to the practical activity of nursing. An argument is constructed to point to the desirability of the development of a virtue of open-mindedness in nurses in order to complement evidence-based practice. Attention is drawn to two failures of open-mindedness (the vices of closed-mindedness and credulousness), which have the potential both to restrict autonomous practice and to cause harm.     

Facilitating the development of moral insight in practice: teaching ethics and teaching virtue

Abstract The teaching of ethics is discussed within the context of insights gleaned from ancient Greek ethics, particularly Aristotle and Plato and their conceptions of virtue (arete, meaning excellence). The virtues of excellence of character (moral virtue) and excellence of intelligence (intellectual virtue), particularly practical wisdom and theoretical wisdom, are considered. In Aristotelian ethics, a distinction is drawn between these intellectual virtues: experience and maturity is needed for practical wisdom, but not for theoretical wisdom. In addition to this, excellence of character is acquired through habitual practice, not instruction. This suggests that there is a need to teach more than theoretical ethics and that the ethics teacher must also facilitate the acquisition of practical wisdom and excellence of character. This distinction highlights a need for various educational approaches in cultivating these excellences which are required for a moral life. It also raises the question: is it possible to teach practical wisdom and excellence of character? It is suggested that virtue, conceived of as a type of knowledge, or skill, can be taught, and people can, with appropriate experience, habitual practice, and good role models, develop excellence of character and become moral experts. These students are the next generation of exemplars and they will educate others by example and sustain the practice of nursing. They need an education which includes theoretical ethics and the nurturing of practical wisdom and excellence of character. For this purpose, a humanities approach is suggested.     

Empirical ethics in action: Lessons from two empirical studies in nursing ethics

Despite the burgeoning of publications in nursing ethics, only more recently has empirical evidence on nursing ethics been published. How nursing ethics can be empirically studied as well as enriched by empirical data will be the focus of this paper. Two empirical studies will be briefly presented and their contribution to ethics discussed. The first one is a quantitative research project about nurses' ethical behavior in daily practice. Using an adapted version of Kohlberg's theory of moral development, this study tried to describe and explore nurses' responses to ethical dilemmas in daily nursing practice. The second study attempted to describe the specificity of residential palliative care. A qualitative approach was used to explore and describe the processes that take place on an inpatient palliative care unit, and the experiences of patients, relatives and palliative care team members. The analysis of the value of both research projects for ethics underlines the power of empirical understanding in the relationship between research and ethics. The need for integration of both qualitative and quantitative research methodologies is argued.     

A pluralist view of nursing ethics

Abstract  This paper makes the case for a pluralist, contextualist view of nursing ethics. In defending this view, I briefly outline two current perspectives of nursing ethics – the Traditional View and the Theory View. I argue that the Traditional View, which casts nursing ethics as a subcategory of healthcare ethics, is problematic because it (1) fails to sufficiently acknowledge the unique nature of nursing practice; and (2) applies standard ethical frameworks such as principlism to moral problems which tend to alienate or undermine nursing ethical concerns. Alternatively, the Theory View, which aims to build an independent and comprehensive theory of nursing ethics, is also found wanting because it (1) fails to sufficiently acknowledge the heterogeneous nature of nursing practices; (2) overemphasizes the differences and undervalues the similarities between nurses and other health professionals; and (3) assumes that one ethical framework can be meaningfully applied across diverse moral problems and contexts.
My alternative, is to argue that nursing ethics inquiry should take a pluralist and critical stance towards available ethical frameworks and the negotiation of the ethical realm. On this view, the search for moral consensus or a unique ethical framework for nursing is replaced by the task of working strategically with multiple frameworks in order to expand the moral agency of nurses and empower them to positively engage with moral uncertainty as an inevitable feature of living a moral life. I conclude by indicating some of the implications that this has for the teaching of nursing ethics.     

Towards understanding the nature of conflict of interest and its application to the discipline of nursing

Most incidences of dishonesty in research, financial investments that promote personal financial gain, and kickback scandals begin as conflicts of interest (COI). Research indicates that healthcare professionals who maintain COI relationships make less optimal and more expensive patient care choices. The discovery of COI relationships also negatively impact patient and public trust. Many disciplines are addressing this professional issue, but little work has been done towards understanding and applying this moral category within a nursing context. Do COIs occur in nursing and are they problematic? What are the morally appropriate responses to COI for our discipline and for individual practicing nurses? In this paper I examine the nature of ‘conflict of interest’ as a general ethical category, its characteristics and its application to our discipline. Conflict of interest is an odd moral category that may actually or potentially result in immoral decisions. The moral justification for COI is grounded prime facie by the moral value of respect for persons and principle of fidelity from which trust is developed and maintained. In review of the historical development, there appears to be consensus on some qualities of COI that are presented. I conclude that making judgements about COI are challenging and often difficult to determine from a nursing perspective. Improving nurses' and professional organizations' awareness of COI and sharpening our ability to respond appropriately when COI arise can reduce potential harm and promote trust in those whom we serve.     

‘Othering’ tactics and treatments of patients with HIV/AIDS: a study of the construct of professional ethics by Thai nurses and nursing trainees

Despite efforts to tighten the code of professional ethics amongst health workers by the Thai authorities, recent studies have shown that discrimination towards HIV-positive patients persists amongst nurses, thus compromising the quality of patient care. Using a framework of ‘Othering’, this paper examines the constructions of professional ethics and duties by a group of Thai nurses, with the aim of identifying problems with the existing approach to discrimination reduction. Twenty semi-structured interviews were conducted with qualified and trainee nurses from a Bangkok nursing college. Following a standard attitudinal measure of HIV-related stigma, participants were asked to explain the reasons behind their responses, and reflect on how these might have shaped their personal and professional encounters with HIV-positive patients. The findings showed that despite heightened awareness about the code of non-discrimination, biases towards HIV-positive patients were evident. Various strategies were employed to maintain a perception of the Self as being in line with the prescribed professional ethical guidelines while leaving personal biases towards HIV-positive patients unchanged. These included the dismissal of discrimination as conducts of ‘Other’ people (i.e. the lay public or unethical colleagues), redefining the nature of nursing duties to avoid providing certain services to HIV-positive patients (e.g. taking blood), and stigmatising patients on the basis of presumed/actual high-risk behaviours (e.g. injecting drug use) instead of HIV status. Broadening nurses’ understanding of the distal factors relating to HIV transmission was discussed as an alternative approach for reducing nurses’ biases towards patients with HIV/AIDS.     

新时期科技期刊编辑职业伦理构建研究

目的 研究新时期编辑职业伦理构建的作用及其核心要素,为提升科技期刊编辑伦理素养、推进编辑出版业健康发展提供参考。方法 采用文献分析法对编辑职业伦理的内涵进行界定,并总结构建新时期科技期刊编辑职业伦理的作用,在此基础上,提出构建编辑职业伦理的核心要素。结果 科技期刊编辑职业伦理主要通过伦理立法规范科技期刊编辑人员的职业行为。构建新时期科技期刊编辑职业伦理能够提升编辑人员的综合素养,促进编辑人员履行社会责任,提升科技期刊质量并促进编辑事业发展。科技期刊编辑职业伦理的构建应基于权利与义务、良心与荣誉、情感与理智、胆识与审慎等核心要素,通过正确行使编辑权利与履行编辑义务、培育编辑良心、保持编辑荣誉感、建立积极理智的编辑职业情感、提升胆识和审慎素养等途径予以实现。结论 构建新时期科技期刊编辑职业伦理具有重要作用,应充分理解科技期刊编辑职业伦理的内涵,并基于相关核心要素进行积极构建。     

What should other healthcare professions learn from nursing ethics

Abstract  This paper analyses the question what other healthcare professions should learn from nursing ethics, e.g. what should medical ethics learn from nursing ethics. I first analyse and reject all strong versions of the claim that nursing ethics is unique, because nursing is a unique practice. I then move to the question of whether the link between nursing ethics and nursing theory can be a model for other areas of healthcare ethics. I provide an analysis of the possibility of creating a theory of medicine and find that there cannot be a theory of medicine, and I argue briefly that this finding is also applicable to nursing. If there cannot be a theory of nursing, this entails that nursing ethics cannot be justifiably based on such a theory. In the final section, I then analyse the success of nursing ethics in resisting certain of the vices of Anglo-American analytic ethics, in particular the reductionism and individualism that characterizes much of healthcare ethics. I conclude that other healthcare ethics could usefully learn from this aspect of nursing ethics.     

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.     

儒家文化与医德建设初探

儒家文化中包含着系统的道德理论和伦理规范,其中很多理论和观点可供我们今天的医德建设所用.本文从三个方面探讨儒家文化与医德建设的关系:一、"仁"、"人伦"观,医德建设之基础;二、"患不知人也"观,医德建设的根本;三、"养气"观,医德建设的最高追求.     

Narrative ethics in nursing for persons with intellectual disabilities1

Abstract Both in the Netherlands and in Britain, practices of ‘life story work’ have emerged in nursing for persons with intellectual disabilities. The narrative approach to care and support may at the same time be considered as an attempt to compensate for the ‘disabled authorship’ of many persons with intellectual disabilities and as a sign of controversy with standard practices of diagnosis and treatment that tend to neglect the personal identities of both clients and care givers, their particular historical and relational contexts and their spiritual needs. This paper argues that narrative ethics not only offers an appropriate moral framework for practices of life story work, but that these practices are a narrative ethics in action. Starting with an account of the concept of ‘life story work’ as it has been introduced in nursing practices in the field of intellectual disability, the paper explains its relationship with key characteristics of narrative ethics. The teleological dimension in narrative ethics and in practices of life story work sparks off a dialectic process of understanding of the client and self‐understanding of the care giver. It also invites a respect for life in its openness toward the future and presupposes an openness toward other possible versions of the life narrative. The phenomenological and hermeneutic‐interpretative methodologies in narrative ethics aim at a ‘sudden moment of intimacy’ in relationships of nurses and clients. The ‘epiphany’ of this essential moment of recognition, insight and engagement cannot, however, be brought about by methodology.     

An internal morality of nursing: what it can and cannot do

It has been claimed that there are certain acts that nurses as people practising nursing (nurses qua nurses) must never do because they are nurses and this is regardless of what the same agent (when not acting in the role of a nurse) should do; that certain actions are not part of proper nursing practice. The concept of an internal morality has been discussed in relation to medicine and has been used to ground the actions proper to medicine in a realist tradition. Although the concept of an internal morality of nursing is not explicitly mentioned in the literature the underpinning ideas about the proper practice of nursing based on philosophical realism I argue equate with it and a discussion of the method of an internal morality can help to understand how arguments against euthanasia (amongst other acts) related to the profession of nursing are far from clear. Ultimately, although the idea of particular acts proper to nurses qua nurses is not clear, the concept of an internal morality can help to get practitioners to see how the profession is tightly linked to moral actions, even so the hard problems in bioethics such as the morality of euthanasia remain hard for all and the easy ones easy for all.