Theories and Concepts

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CHAPTER 1 Introduction to Ethics ...... 2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION CHAPTER 2 NOTIntroduc FORtion SALE to Bioethics OR DISTRIBUTION and Ethical Decision Making ...... 27 CHAPTER 3 Ethics in Professional Nursing Practice . . . . . 59 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning,Karen L. Rich LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A seed will only become a flower if it gets sun and water. —Louis Gottschalk

After reading this chapter, the reader should be able to do the following: 1. Define the terms ethics and morals and discuss philosophical uses of these terms. 2. Discuss systems of moral reasoning as they have been used throughout history. © Jones & Bartlett3. Evaluate Learning, a variety of ethical LLC theories and approaches to use© inJones personal & and Bartlett professional Learning, LLC NOT FOR SALErelationships. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

▸▸ Introduction to Ethics Ethical directives are not always clearly evident, and people sometimes disagree about © Jones & Bartlett Learning,In the world LLC today, “we are in the throes© of Jones a what & isBartlett right and Learning, wrong. These LLC factors lead NOT FOR SALE OR DISTRIBUTIONgiant ethical leap that is essentially embracingNOT FORsome SALE people ORto believe DISTRIBUTION ethics can be based all of humankind” (Donahue, 1996, p. 484). merely on personal opinions. However, if Scientific and technological advances, eco- nurses are to enter into the global dialogue nomic realities, pluralistic worldviews, and about ethics, they must do more than practice global communication make it difficult for ethics based simply on their personal opin- nurses© to Jones ignore the& Bartlettimportant Learning,ethical issues LLCions, their intuition, or the ©unexamined Jones &beliefs Bartlett Learning, LLC in theNOT world FORcommunity, SALE their OR everyday DISTRIBUTION lives, proposed by other people.NOT It is important FOR SALE for OR DISTRIBUTION and their work. As controversial and sensitive nurses to have a basic understanding of the ethical issues continue to challenge nurses and concepts, principles, approaches, and theories other healthcare professionals, many profes- used in studying ethics throughout history so sionals have begun to develop an appreciation they can identify and analyze ethical issues and © Jones &for Bartlett traditional Learning, philosophies LLCof ethics and the dilemmas© relevantJones to & nurses Bartlett in the Learning, 21st cen- LLC NOT FORdiverse SALE viewpoints OR DISTRIBUTION of others. tury. Mature,NOT ethical FOR sensitivities SALE OR are criticalDISTRIBUTION to

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ethical practice, and as Hope (2004) proposed, Throughout history, people, based on their “we need to© develop Jones our & hearts Bartlett as well Learning, as our culture, LLC have engaged in actions ©they Jones believe & Bartlett Learning, LLC minds” (p. 6).NOT FOR SALE OR DISTRIBUTIONare justifiable only to have the lightNOT of reason FOR SALE OR DISTRIBUTION later show otherwise. Following a charismatic but egocentric leader such as Adolf Hitler is an The Meaning of Ethics and Morals example of such a practice. When narrowly defined according to its origi- © Jonesnal use, & ethics Bartlett is a branch Learning, of philosophy LLC used to © Jones & Bartlett Learning, LLC NOTstudy FOR ideal SALE human OR behavior DISTRIBUTION and ways of being. ETHICAL REFLECTIONNOT FOR SALE OR DISTRIBUTION The approaches to ethics and the meanings of related concepts have varied over time among Consider a person who believes abortion is philosophers and ethicists. For example, Ar- wrong based on the position that human life istotle believed ideal behaviors are practices is sacred. Can this same person logically justify © Jones & Bartlettleading Learning, to the end LLC goal of eudaimonia, which © Jonesthat the death& Bartlett penalty is Learning,a moral action? LLC NOT FOR SALE ORis synonymous DISTRIBUTION with a high level of happiness NOTDiscuss. FOR SALE OR DISTRIBUTION or well-being; on the other hand, Immanuel Kant, an 18th-century philosopher and eth- icist, believed ideal behavior is acting in ac- As contrasted with ethics, morals are cordance with one’s duty. For Kant, well-being specific beliefs, behaviors, and ways of being meant having© theJones freedom & Bartlettto exercise Learning,auton- derived LLC from doing ethics. One’s© morals Jones are & Bartlett Learning, LLC omy (self-determination),NOT FOR SALEnot being OR used DISTRIBUTION as judged to be good or bad throughNOT systematic, FOR SALE OR DISTRIBUTION a means to an end, being treated with dignity, ethical analysis. The reverse of morality is im- and having the capability to think rationally. morality, which means a person’s behavior is As a philosophical discipline of study, in opposition to accepted societal, religious, ethics is a systematic approach to understand- cultural, or professional ethical standards © Jonesing, analyzing, & Bartlett and distinguishingLearning, LLCmatters of and principles;© examples Jones of& immoralityBartlett Learning,in- LLC NOTright FOR and SALE wrong, ORgood DISTRIBUTIONand bad, and admirable clude dishonesty,NOT fraud, FOR murder, SALE and sexuallyOR DISTRIBUTION and dishonorable as they relate to the well-being abusive acts. Amoral is a term used to refer of and the relationships among sentient beings. to actions normally judged as immoral, but Today, even relationships between people and the actions are done with a lack of concern their environment have entered the realm of eth- for good character, one’s duty, or the conse- © Jones & Bartlettics. Learning, Ethical determinations LLC are applied through © quences.Jones For& Bartlettexample, murder Learning, is immoral, LLC but NOT FOR SALE ORthe useDISTRIBUTION of theories, approaches, and codes of NOTif a person FOR commits SALE murderOR DISTRIBUTION with absolutely no conduct, such as codes developed for profes- sense of remorse or maybe even with a sense of sions and religions. Ethics is an active process pleasure, the person is acting in an amoral way. rather than a static condition, so some ethicists Acts are considered to be nonmoral if moral use the expression doing ethics. When people standards essentially do not apply to the acts; are doing ethics,© Jones they need & Bartlett to support Learning, their for LLC example, choosing between cereal© Jones or toast & Bartlett Learning, LLC beliefs and assertionsNOT FOR with soundSALE reasoning. OR DISTRIBUTIONand jam for breakfast is a nonmoralNOT decision. FOR SALE OR DISTRIBUTION Feelings and emotions are a normal part When people consider matters of ethics, of everyday life and can play a legitimate role they usually are considering matters about in doing ethics. However, people sometimes freedom in regard to personal choices, one’s allow their emotions to overtake good reason- obligations to other sentient beings, or judg- © Jonesing; when & Bartlett this happens, Learning, it does not LLC provide a ments about human© Jones character. & Bartlett The term Learning,un- LLC NOTgood FOR foundation SALE OR for ethics-relatedDISTRIBUTION decisions. ethical is used toNOT describe FOR ethics SALE in its negativeOR DISTRIBUTION Evaluations generated through the practice of form, for instance, when a person’s character ethics require a balance of emotion and reason. or behavior is contrary to admirable traits

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or the code of conduct endorsed by one’s so- that are right or wrong, good or bad, admir- ciety, ©community, Jones & Bartlettor profession. Learning, Because LLCable or dishonorable. When© using Jones the method& Bartlett Learning, LLC the wordNOT ethics FOR is usedSALE when OR one DISTRIBUTION may actu- of normative ethics, inquiriesNOT are FORmade aboutSALE OR DISTRIBUTION ally be referring to a situation of morals, the how humans should behave, what ought to be process-related, or doing, conception of ethics done in certain situations, what type of char- is sometimes overlooked today. People often acter one should have, or the type of person use the word ethics when referring to a collec- one should be. © Jones &tion Bartlett of actual Learning,beliefs and behaviors, LLC thereby © Jones & Bartlett Learning, LLC NOT FORusing SALE the terms OR DISTRIBUTIONethics and morals interchange- NOT FOR SALE OR DISTRIBUTION ably. In this text, some effort has been made to LEGAL PERSPECTIVE distinguish the words ethics and morals based on their literal meanings; however, because of Common law is based on customs and common uses, the terms have generally been previously decided cases rather than on © Jones & Bartlett Learning,used interchangeably. LLC © Jonesstatutes. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONThe following features regarding the NOTcon- FOR SALE OR DISTRIBUTION cepts of morals and ethics were adapted from Billington (2003): Outcomes of normative ethics are the prescriptions derived from asking normative ■■ Probably the most important feature about questions. These prescriptions include ac- ethics and morals is that no one can avoid © Jones & Bartlett Learning, LLCcepted moral standards and© codes.Jones One & suchBartlett Learning, LLC making ethical decisions because social accepted moral standard identified by Beau- connectionsNOT FOR with SALE others OR necessitates DISTRIBUTION that NOT FOR SALE OR DISTRIBUTION champ and Childress (2013) is the common people must consider moral and ethical morality. The common morality consists of actions. normative beliefs and behaviors that members ■■ Other people are always involved with of a society generally agree about and are fa- one’s ethical decisions. Private morality © Jones & Bartlett Learning, LLC miliar to© most Jones members & Bartlett of the society. Learning, These LLC does not exist. NOT FOR SALE OR DISTRIBUTION norms developNOT FORwithin SALEthe context OR ofDISTRIBUTION history ■■ Ethical decisions matter because one per- and form a “social compact” (p. 3) about how son’s decisions often affect someone else’s people should behave. Because it forms what life, self-esteem, or happiness. can be thought of as a universal morality with ■■ It is difficult to reach definite conclusions a wide scope, the common morality provides or resolutions in ethical debates. © Jones & Bartlett Learning, LLC © Jonessociety & Bartlett with a framework Learning, of ethical LLC stability. ■■ In the area of morals and ethics, people The common morality contains rules of ob- NOT FOR SALE OR DISTRIBUTIONcannot exercise ethical judgments withNOT- FOR SALE OR DISTRIBUTION ligation, character traits, and common moral out being given a choice; in other words, a ideals. The beliefs that it is moral to tell the necessity for making a sound ethical judg- truth, exhibit loving-kindness, and be charita- ment is being able to choose an option ble are part of the common morality, whereas from among a number of choices. © Jones & Bartlett Learning, LLCabortion is not a part of the© common Jones morality & Bartlett Learning, LLC ■■ People use moral reasoning to make moral because of the many varying positions about judgmentsNOT FOR or to SALE discover OR right DISTRIBUTION actions. NOT FOR SALE OR DISTRIBUTION its rightness or wrongness. Gert, Culver, and Clouser (2006) contended that many people Types of Ethical Inquiry mistakenly believe there is little agreement Ethics is categorized according to three types about moral matters, whereas in reality, con- © Jones &of inquiryBartlett or study: Learning, normative LLC ethics, metaeth- troversial© issues Jones are actually & Bartlett the focus Learning, of only a LLC NOT FORics, SALE and descriptive OR DISTRIBUTION ethics. The first approach, small partNOT of ethical FOR decision SALE making. OR DISTRIBUTION normative ethics, is an attempt to decide or Particular nonuniversal moralities ad- prescribe values, behaviors, and ways of being hered to by specific groups can be distinguished

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from the common morality (Beauchamp & ethically related concepts and theories, such as Childress, 2013).© Jones Particular & Bartlettmoralities, Learning,such as the LLC meaning of good, happiness, ©and Jones virtuous & Bartlett Learning, LLC those based NOTon a certain FOR ethical SALE theory OR orDISTRIBUTION ap- character. For example, a nurse whoNOT is actively FOR SALE OR DISTRIBUTION proach (see those discussed later in this chap- engaged in a metaethical analysis might try ter) or a profession’s moral norms and codes, to determine the meaning of a good nurse– are heavily content laden and specific rather patient relationship. than general in nature. Yet these nonuniversal Descriptive ethics is often referred to as © Jonesmoralities & Bartlett generally are Learning, consistent with LLC socially a scientific rather© thanJones a philosophical & Bartlett ethical Learning, LLC NOTsanctioned FOR SALE beliefs OR falling DISTRIBUTION under a common inquiry. It is an NOTapproach FOR used SALE when research OR DISTRIBUTION- morality. The Code of Ethics for Nurses with ers or ethicists want to describe what people Interpretive Statements (American Nurses As- think about morality or when they want to sociation, 2015) is a specific morality for profes- describe how people actually behave, that is, sional nurses in the United States. A normative their morals. Professional moral values and © Jones & Bartlettbelief Learning, posited in the LLC code is that nurses ought to © behaviorsJones &can Bartlett be described Learning, through nursingLLC NOT FOR SALE ORbe compassionate; DISTRIBUTION that is, nurses should work NOTresearch. FOR An SALE example OR of DISTRIBUTIONdescriptive ethics is to relieve suffering. Nurses have specific obli- research that identifies nurses’ attitudes re- gations that are different from the obligations garding telling patients the truth about their of other people. As risks and dangers for nurses terminal illnesses. become more complex, the profession’s morality must evolve© Jonesand be continually & Bartlett reexamined. Learning, LLC © Jones & Bartlett Learning, LLC Nurses mightNOT ask themselves FOR SALE these ORnormative DISTRIBUTION Ethical Perspectives NOT FOR SALE OR DISTRIBUTION questions: Do I have an obligation to endanger Though it may seem somewhat contrary to my life and the life of my family members by the contention that there is an understandable working during a highly lethal influenza pan- common morality, ethical thinking, valuing, demic? Do I have an obligation to stay at work and reasoning are believed to fall somewhere © Jonesin a hospital & Bartlett during Learning, a category 5 LLC hurricane along a continuum© Jones between & Bartletttwo opposing Learning, LLC NOTrather FOR than SALE evacuating OR DISTRIBUTION with my family? The views: ethical relativismNOT FOR and SALEethical objectiv OR DISTRIBUTION- answers to these questions may generate strong ism. After reading the following discussion emotions, confusion, or feelings of guilt. about ethical perspectives, it probably will seem sensible to reflect on the meaning of philosophy and why ethics is a philosophical pur- © Jones & Bartlett LEGALLearning, PERSPECTIVE LLC © suit.Jones Ethical & issuesBartlett and discussionsLearning, frequently LLC NOT FOR SALE OR DISTRIBUTION NOThave FOR blurred SALE edges. OR They DISTRIBUTION do not fit into a Some actions may be legal, but people do not circumscribed mold. However, this does not agree that the actions are moral. Research and make doing ethics merely an opinion-based debate issues such as the following: endeavor, though one can reasonably argue Breaking promises that extremes of ethical relativism come close. Abortion © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Palliative or terminal sedation NOT FOR SALE OR DISTRIBUTIONEthical Relativism NOT FOR SALE OR DISTRIBUTION Ethical relativism is the belief that it is accept- The focus of metaethics, which means able for ethics and morality to differ among about ethics, is not an inquiry about what persons or societies. There are two types of © Jonesought &to Bartlettbe done or Learning, which behaviors LLC should ethical relativism:© Jones ethical &subjectivism Bartlett Learning,and LLC NOTbe FOR prescribed. SALE Instead,OR DISTRIBUTION metaethics is con- cultural relativismNOT (Brannigan FOR SALE & Boss, OR 2001). DISTRIBUTION cerned with understanding the language of People who subscribe to a belief in ethical morality through an analysis of the meaning of subjectivism believe “individuals create

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their own morality [and] there are no objec- or approaches are mutually exclusive, theor- tive moral© Jones truths—only & Bartlett individual Learning, opinions” LLCies and approaches often ©overlap Jones when & usedBartlett Learning, LLC (2001,NOT p. 7). People’sFOR SALE beliefs about OR actionsDISTRIBUTION being in practice. “Moral judgmentNOT is aFOR whole SALE into OR DISTRIBUTION right or wrong or good or bad depend on how which we must fit principles, character and people feel about actions rather than on reason intentions, cultural values, circumstances, and or systematic ethical analysis. What one person consequences” (Brannigan & Boss, 2001, p. 23). believes to be wrong might not be viewed as © Jones &wrong Bartlett by one’s Learning, neighbor, depending LLC on vari- © Jones & Bartlett Learning, LLC NOT FORations SALE in opinionsOR DISTRIBUTION and feelings. These differ- NOT FOR SALE OR DISTRIBUTION ences are acceptable to ethical subjectivists. ETHICAL REFLECTION Ethical subjectivism has been distin- Where does your personal worldview fall on guished from cultural relativism. Pence (2000) the continuum between ethical relativism and cultural relativism defined as “the ethical ethical objectivism? Defend your position. © Jones & Bartlett Learning,theory that LLC moral evaluation is rooted in© and Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONcannot be separated from the experience,NOT be- FOR SALE OR DISTRIBUTION liefs, and behaviors of a particular culture, and hence, that what is wrong in one culture ▸ may not be so in another” (p. 12). People who ▸ Values and Moral are opposed to cultural relativism argue that Reasoning when© it Jonesis practiced & Bartlettaccording toLearning, its extreme LLC © Jones & Bartlett Learning, LLC or literalNOT meaning, FOR thisSALE type ofOR thinking DISTRIBUTION can be Because ethics falls withinNOT the abstract FOR disciSALE- OR DISTRIBUTION dangerous because it theoretically may sup- pline of philosophy, ethics involves many per- port relativists’ exploitative or hurtful actions spectives of what people value as meaningful (Brannigan & Boss, 2001). An example of and good in their lives. A value is something cultural relativism is the belief that the act of of worth or highly regarded. Values refer to © Jones &female Bartlett circumcision, Learning, sometimes LLC called female one’s evaluative© Jones judgments & Bartlett about what Learning, one be- LLC NOT FORgenital SALE mutilation, OR DISTRIBUTION is a moral practice. Though lieves is NOTgood orFOR makes SALE something OR desirable.DISTRIBUTION not considered to be a religious ritual, this act The things people esteem to be good influence is considered ethically acceptable by some how personal character develops and people groups in countries with a Muslim or an Egyp- think and subsequently behave. Professional tian Pharaonic heritage. In most countries and values are outlined in professional codes. A © Jones & Bartlett Learning,cultures, however, LLC it is considered to be a grave© Jones fundamental & Bartlett position Learning, in the American LLC Nurses NOT FOR SALE OR DISTRIBUTIONviolation in accordance with the UnitedNOT Na- FORAssociation’s SALE CodeOR ofDISTRIBUTION Ethics for Nurses with In- tions’ Declaration of Human Rights. terpretive Statements (2015) is that professional and personal values must be integrated. Values and moral reasoning in nursing fall under Ethical Objectivism the domain of normative ethics; that is, pro- Ethical© objectivismJones & Bartlettis the belief Learning, that univer- LLCfessional values contained ©in Jonesthe code & guide Bartlett Learning, LLC sal, orNOT objective, FOR moral SALE principles OR DISTRIBUTIONexist. Many nurses in how they ought toNOT be and FOR behave. SALE OR DISTRIBUTION philosophers and healthcare ethicists hold Reasoning is the use of abstract thought this view, at least to some degree, because they processes to think creatively, answer questions, strictly or loosely adhere to a specific approach solve problems, and formulate strategies for in determining what is good. Examples of ob- one’s actions and desired ways of being. When © Jones &jectivist Bartlett ethical Learning, theories and LLC approaches are people participate© Jones in & reasoning, Bartlett they Learning, do not LLC NOT FORdeontology, SALE OR utilitarianism, DISTRIBUTION and natural law merely acceptNOT the FOR unexamined SALE beliefs OR DISTRIBUTIONand ideas theory, which are discussed later in this chapter. of other people. Reasoning involves thinking Though some ethicists believe these theories for oneself to determine if one’s conclusions

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are based on good or logical foundations. More Nurse: It means my patients are well taken specifically, moral© Jones reasoning & Bartlett pertains Learning,to rea- LLCcare of. © Jones & Bartlett Learning, LLC soning focusedNOT on FOR moral SALE or ethical OR issues.DISTRIBUTION Socrates: How do you know yourNOT patients FOR SALE OR DISTRIBUTION Moral reasoning for nurses usually occurs in the are well taken care of? context of day-to-day relationships between This line of questioning should continue until nurses and the recipients of their care and be- the concepts and positions stemming from tween nurses and their coworkers and others the original question are thoroughly explored. © Joneswithin &organizations. Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Socratic questioning does not mean one ends Different values, worldviews, and ways NOT FOR SALE OR DISTRIBUTION up with a final NOTanswer; FOR however, SALE this formOR DISTRIBUTIONof of moral reasoning have evolved throughout discussion encourages people to continually history and had different points of emphasis expand their thinking in critical and reflect- in various historical periods. In regard to some ive ways. approaches to reasoning about moral issues, © Jones & Bartlettwhat Learning, was old becomes LLC new again, as in the case © Jones & Bartlett Learning, LLC NOT FOR SALE ORof the DISTRIBUTION renewed popularity of virtue ethics, or NOT FOR SALE OR DISTRIBUTION the concept of reasoning as would be practiced ETHICAL REFLECTION by a person with good character. In small groups, begin a Socratic dialogue Ancient Greece with classmates or colleagues. Develop your © Jones & Bartlett Learning, ownLLC questions, or use one of the following© Jones & Bartlett Learning, LLC In Western NOThistory, FOR much SALE of what OR is known DISTRIBUTION examples. A Socratic dialogue shouldNOT be civil, FOR SALE OR DISTRIBUTION about formal moral reasoning generally be- nonthreatening, and supportive of learning; gan with the ancient Greeks, especially with it is not a means to belittle people who have the philosophers Socrates (ca. 469–399 BCE), beliefs different from one’s own. After your Plato (ca. 429–347 BCE), and Aristotle (384– dialogue, share your understandings with © Jones322 BCE). & Bartlett Though there Learning, are no primary LLC texts other groups. © Jones & Bartlett Learning, LLC NOTof FOR the teachings SALE ofOR Socrates DISTRIBUTION (what we have of ■■ What doesNOT caring meanFOR in SALEnursing? OR DISTRIBUTION his teachings were recorded by Plato), it is ■■ What does competence mean in nursing? known that Socrates was an avid promoter of ■■ What is academic integrity? moral reasoning and critical thinking among the citizens of Athens. Socrates is credited with the statement “the unexamined life is not © Jones & Bartlett Learning, LLC © JonesSocrates & Bartletthad many Learning, friends and LLC allies worth living,” and he developed a method of who believed in his philosophy and teach- NOT FOR SALE ORreasoning DISTRIBUTION called Socratic questioning, or the NOT FOR SALE OR DISTRIBUTION ings. In fact, Socrates was such a successful Socratic method, which is still used today. and well-known teacher of philosophy and In using his method of inspiring open- moral reasoning in Athens that he was put to mindedness and critical thinking, Socrates death for upsetting the sociopolitical status posed challenging questions and then would © Jones & Bartlett Learning,quo. LLC Socrates was accused of corrupting© Jones the & Bartlett Learning, LLC ask another question about the answers he NOT FOR SALE OR DISTRIBUTIONyouth of Athens who, under his NOTtutelage, FOR be- SALE OR DISTRIBUTION received. A goal of participating in a Socratic gan to question their parents’ wisdom and reli- dialogue is to investigate the accuracy, clarity, gious beliefs. These accusations of corruption and value of one’s intellectual positions and be- were based on Socrates’s encouraging people liefs. An example of his method of questioning to think independently and question dogma is as follows: © Jones & Bartlett Learning, LLC generated by the© rulingJones class. & ThoughBartlett he Learning,was LLC NOT FORSocrates: SALE Why OR should DISTRIBUTION a nurse study ethics? sentenced to deathNOT by FORthe powerful, SALE elite OR men DISTRIBUTION Nurse: To be a good nurse. within his society, Socrates refused to apolo- Socrates: What is a good nurse? gize for his beliefs and teachings. He ultimately

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chose to die by drinking poisonous hemlock believed the influences of these three parts of rather© than Jones deny his& values.Bartlett Learning, LLCthe soul exist in greater to© lesserJones degrees & Bartlett in Learning, LLC Plato,NOT Socrates’s FOR SALE student, OR is DISTRIBUTIONbelieved by each person. Therefore, oneNOT person FOR may SALE be OR DISTRIBUTION some to have been the most outstanding phi- more disposed to intellectual pursuits as com- losopher to have ever lived. Plato’s reasoning is pared to another person who is more inter- based on his belief that there are two realms of ested in physical pleasures. reality. The first is the realm of Forms, which Plato associated the tripartite soul with © Jones &transcends Bartlett time Learning, and space. According LLC to Plato, three classes© Jones of Greek & Bartlett society Learning,and one’s LLC NOT FORan SALE eternal, ORperfect, DISTRIBUTION and unchanging ideal copy best-suitedNOT occupation. FOR SALE People ORwere DISTRIBUTIONbelieved (Form) of all phenomena exists in the realm of to have an individual aptitude particularly Forms, which is beyond everyday human ac- suited to them and their purpose in society: cess. Plato believed the realm of Forms contains ■■ Philosopher kings were associated with the essence of concepts and objects and even the Faculty of Reason and wisdom. © Jones & Bartlett Learning,the essence LLC of objects’ properties. Essences© ex Jones- & Bartlett Learning, LLC ■■ Societal guardians were associated with NOT FOR SALE OR DISTRIBUTIONisting in the realm of Forms include, for examNOT- FOR theSALE Faculty OR of SpiritDISTRIBUTION and protecting others. ple, a perfect Form of good, redness (the color ■■ Artisans and craftsmen were associated red), or a horse. In the realm of Forms, the es- with the Faculty of Appetite and technical sence of good exists as ideal Truth, and redness work. (a particular property of some objects, such as an apple)© Jones exists as &the Bartlett color red in Learning, its most per- LLC © Jones & Bartlett Learning, LLC fect state.NOT A horseFOR in SALE the realm OR of FormsDISTRIBUTION is the FOCUS FOR DEBATE NOT FOR SALE OR DISTRIBUTION perfect specimen of the animal that is a horse, and this perfect horse contains all the horse- If Florence Nightingale were alive today and ness factors that, for example, distinguish a she took the position that nurses represent horse from a cow. Plato considered the world Plato’s guardian class and physicians represent © Jones &of FormsBartlett to be Learning, the real world, LLC though humans the artisan© Jones class, would & sheBartlett be correct? Learning, LLC NOT FORdo SALE not live OR in this DISTRIBUTION world. NOT FOR SALE OR DISTRIBUTION The second realm is the world of Appear- ances, which is the everyday world of imper- Florence Nightingale, the founder of mod- fect, decaying, and changing phenomena; this ern nursing, was a passionate student of an- is the world in which humans live. The under- cient Greek philosophy. Nightingale may have © Jones & Bartlett Learning,lying purpose, LLC or goal, of imperfect phenom© Jones- aligned & Bartlett the function Learning, of nurses with LLC the Faculty NOT FOR SALE OR DISTRIBUTIONena in the world of Appearances is to emulateNOT FORof Spirit SALE (LeVasseur, OR DISTRIBUTION 1998). Because of her ed- their associated essences and perfect Forms. ucation in classical Greek literature and culture For example, a horse’s purpose in life is to and her views about nursing, LeVasseur pro- strive toward becoming identical to the perfect posed that Nightingale might have compared specimen of a horse that exists in the world of her purpose as a nurse with the role of a societal Forms.© Jones & Bartlett Learning, LLCguardian. In contrast, early© physicians, Jones &whose Bartlett Learning, LLC PlatoNOT also FOR proposed SALE that OR humans DISTRIBUTION have a profession developed throughNOT apprenticeship FOR SALE OR DISTRIBUTION tripartite soul. The three parts of the soul con- guilds, which emphasized technical practices, sist of the Faculty of Reason, associated with might be compared to the artisan class. thought and Truth, which is located in one’s One of Plato’s most famous stories about head; the Faculty of Spirit, which expresses reasoning is his allegory of the cave. In this © Jones &love, Bartlett beauty, and Learning, the desire forLLC eternal life and story, a group© Jones of people & livedBartlett their lives Learning, chained LLC NOT FORis SALE located inOR one’s DISTRIBUTION chest; and the Faculty of Ap- to the floorNOT of aFOR cave. SALEBehind themOR DISTRIBUTIONburned a petite, which is an expression of human desires fire that cast shadows of people moving on the and emotions and is located in one’s gut. Plato wall in front of the people who were chained.

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The chained prisoners believed the shadows Aristotle’s conception of phronesis is sim- were actually© realJones people. & BartlettWhen one Learning,of the ilar LLC to Plato’s conception of the virtue© Jones of pru -& Bartlett Learning, LLC prisoners wasNOT freed FOR from his SALE chains, OR he left DISTRIBUTION the dence. Wisdom is focused on the goodNOT achieved FOR SALE OR DISTRIBUTION cave. First, he was blinded by the brightness of from being wise, which means one knows how the sun. After his sight adjusted to the light, he to act in a particular situation, deliberates well, saw objects he realized were more real than the and has a disposition embodying excellence of shadows within the cave. The freed person re- character. Therefore, in ancient Greece, pru- © Jonesturned & to Bartlettthe cave to encourageLearning, the LLCother pris- dence is more than© Jones simply having & Bartlett good inten Learning,- LLC NOToners FOR to SALEbreak their OR chains DISTRIBUTION and enter the more tions or meaningNOT well; itFOR is knowing SALE what OR to doDISTRIBUTION expansive world of reality. The meaning of and how to be but also involves transforming this story has been interpreted in many ways. knowledge into well-reasoned actions. Aris- Whatever Plato’s intended meaning, the story totle believed people are social beings whose does prompt people to think about the prob- reasoning should lead them to be good citizens © Jones & Bartlettlems Learning, that result when LLC they remain chained by © andJones friends & and Bartlett to act in Learning,moderate ways. LLC NOT FOR SALE ORtheir DISTRIBUTION closed minds and flawed reasoning. NOT FOR SALE OR DISTRIBUTION Plato’s student Aristotle developed science, logic, and ethics to world-altering pro- The Middle Ages portions. Though he was influenced by Plato, After the Roman Empire was divided by bar- Aristotle took a more practical approach to barians and the Roman Emperor Romulus was reasoning than© Jones believing & in Bartlett an otherworldly Learning, dethroned LLC (ca. 476 CE), the golden© Jonesage of in -& Bartlett Learning, LLC realm of idealNOT Forms. FOR HeSALE was ORguided DISTRIBUTION in tellectualism and cultural progressNOT in Western FOR SALE OR DISTRIBUTION his reasoning by his belief in the importance Europe ended. The next historical period was of empirical inquiry. He also believed all the Middle, or Dark, Ages, which lasted until things have a purpose, or end goal (telos), sim- about 1500 CE. In the gap left by the failed ilar to Plato’s proposition that the goal of all political system of Rome, Christianity became © Jonesthings &is toBartlett strive to beLearning, like their perfect LLC Form. the dominant religion© Jones in Western & Bartlett Europe Learning, as LLC NOTIn FOR Nicomachean SALE EthicsOR DISTRIBUTION, Aristotle (trans. 2002) the Catholic ChurchNOT took FOR on theSALE powerful OR role DISTRIBUTION discussed practical wisdom (phronesis) as of educating European people. Christianity is being necessary for deliberation about what is a monotheistic (one God) revelatory religion, good and advantageous if people want to move whereas ancient Greek philosophy was based toward their human purpose, or desired end on the use of reason and polytheism (many © Jones & Bartlettgoal, Learning, of happiness LLC or well-being (eudaimonia). © gods).Jones Because & Bartlett Greek philosophy Learning, was believedLLC NOT FOR SALE ORAristotle DISTRIBUTION believed a person needs education NOTto be FOR heretical, SALE its examinationOR DISTRIBUTION was discour- to cultivate phronesis to achieve intellectual aged during the church-dominated Middle excellence. Ages. However, it is interesting that two Cath- olic saints, Augustine and Aquinas, who provided the major ethical influence during the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ETHICAL REFLECTION Middle Ages, were both influenced by the an- NOT FOR SALE OR DISTRIBUTIONcient Greeks. NOT FOR SALE OR DISTRIBUTION Saint Augustine (354–430 CE) is often Compare Plato’s allegory of the cave to critical considered to be the Plato of the Middle Ages. thinking in nursing. Think of a few personal Though Augustine was a Christian and Plato examples when you were chained in the cave. What were the circumstances? What were the was a non-Christian, Augustine’s belief in a © Jonesoutcomes? & Bartlett What made Learning, a difference inLLC your heavenly place ©of Jonesunchanging & Bartlettmoral truths Learning, is LLC NOT FORthinking? SALE OR DISTRIBUTION similar to Plato’sNOT belief FOR in the SALE realm ORof ideal DISTRIBUTION Forms. Augustine believed these Truths are

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imprinted by God on the soul of each human well-being) through the cultivation of excel- being.© According Jones &to Augustine,Bartlett oneLearning, has a duty LLClent intellect and moral character.© Jones & Bartlett Learning, LLC to loveNOT God, FOR and moral SALE reasoning OR DISTRIBUTION should dir- Aquinas expanded Aristotle’sNOT FOR concep SALE- OR DISTRIBUTION ect one’s senses in accordance with that duty; tion of the end goal of perfect happiness and being subject to this obligation is what leads grounded the requirements for happiness in to moral perfection. Generally, Saint Augus- the knowledge and love of God and Christian tine believed in the existence of only good, virtues. Aquinas replaced Aristotle’s emphasis © Jones &similar Bartlett to how Learning, the essence LLC of good would on the virtue© Jones of pride & with Bartlett an emphasis Learning, on the LLC NOT FORexist SALE if it wereOR anDISTRIBUTION ideal Form. Therefore, evil virtue ofNOT humility. FOR Aristotle SALE believed OR DISTRIBUTION pride is is present only when good is missing or has in an important characteristic of independent, some way been perverted from its existence as strong men, whereas Aquinas valued the char- an ideal Truth. acteristic of humility because it represented to Augustine was 56 years old during the fall him one’s need to depend on the benevolence © Jones & Bartlett Learning,of the Roman LLC Empire. In one of his most© faJones- of God.& Bartlett In addition Learning, to virtue ethics, LLC Aquinas NOT FOR SALE OR DISTRIBUTIONmous writings, The City of God, Augustine NOTused FORis associated SALE with OR a DISTRIBUTIONbelief in reasoning accord- the fall of the Roman Empire to explain a phi- ing to the natural law theory of ethics. Both of losophy sometimes compared to Plato’s concep- these ethical approaches are covered later in tion of the worlds of Forms and Appearances. this chapter. People who live according to the spirit live in the City© Jonesof God (world& Bartlett of perfection/Forms), Learning, LLCModern Philosophy© and Jones the & Bartlett Learning, LLC whereasNOT people FOR who SALE live according OR DISTRIBUTION to the flesh NOT FOR SALE OR DISTRIBUTION live in the City of Man (world of imperfection/ Age of Enlightenment Appearances). To move away from evil, one The period of modern philosophy began when must have the grace of God. Augustine viewed the Catholic Church, the major intellectual humans as finite beings who must have the force during the Middle Ages, began to have a © Jones &divin Bartlette aid of graceLearning, to bridge LLC the gap required diminishing© Jones influence & within Bartlett society Learning, while the LLC NOT FORto SALE have a ORrelationship DISTRIBUTION with the infinite being influenceNOT of science FOR began SALE to increase. OR DISTRIBUTION The sci- of God. entific revolution began in 1543, when Coper- The Crusades influenced Europe’s ex- nicus discovered that the Earth and humans odus from the Dark Ages. When Christians are not the center of the universe, but this rev- entered Islamic lands, such as Spain, Portugal, olution did not rapidly advance until the 17th © Jones & Bartlett Learning,and North LLC Africa, they were reintroduced© toJones century, & Bartlett when Kepler Learning, and Galileo LLC moved sci- NOT FOR SALE OR DISTRIBUTIONintellectualism, including texts of the ancientNOT FORentific SALE debates OR to the DISTRIBUTION forefront of society. Greeks, especially Aristotle. The moral teach- With these changes came a new freedom ings of Saint Thomas Aquinas (1224–1274) in human moral reasoning based on people are sometimes viewed as a Christianized ver- being autonomous, rational-thinking crea- sion of Aristotle’s ethical teachings. Aquinas tures rather than primarily being influenced tried ©to Jonesreconcile & Aristotle’s Bartlett teachings Learning, with LLCand controlled by Church© dogma Jones and & rules. Bartlett Learning, LLC the teachingsNOT FOR of the SALE Catholic OR Church. DISTRIBUTION Like During the 18th-century EnlightenmentNOT FOR SALE era, OR DISTRIBUTION Aristotle, Aquinas believed people have a de- humans believed they were coming out of the sirable end goal, or purpose, and develop- darkness of the Middle (Dark) Ages into the ing excellences of character (virtues) leads to light of true knowledge. human happiness and good moral reasoning. Some scientists and philosophers were © Jones &Aristotle’s Bartlett non-Christian Learning, moral LLC philosophy is bold enough© Jones to believe & Bartletthumans could Learning, ultim- LLC NOT FORbased SALE on humansOR DISTRIBUTION moving toward an end goal, ately beNOT perfected FOR and SALE all knowledge OR DISTRIBUTION could or dynamic state, of eudaimonia (happiness or be discovered. As the belief in empirical

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science grew, a new way of thinking was ush- According to people who believe in the truth ered in that ©compared Jones both & Bartlett the universe Learning, and of theLLC fact/value distinction, the chance© Jones of Sara & Bartlett Learning, LLC people to machines.NOT FOR Many SALE scientists OR and DISTRIBUTION phi- spreading her fleas to the sofa mightNOT be FORa fact SALE OR DISTRIBUTION losophers believed the world, along with its in- if she sleeps on it, but determining that having habitants, could be reduced through analyses fleas on the sofa is a bad thing is based on only into their component parts. These reduction- one’s values or feelings. ists hoped that after most or all knowledge was © Jonesdiscovered, & Bartlett the universe Learning, and human LLC behavior © Jones & Bartlett Learning, LLC NOTcould FOR be SALE predicted OR and DISTRIBUTION controlled. People still PostmodernNOT Era FOR SALE OR DISTRIBUTION demonstrate evidence of this way of thinking After the scientific hegemony of the Enlight- in health care today when cure is highly valued enment era, some people began to question over care and uncertainty is considered to be whether a single-minded allegiance to science something that can or needs to be eliminated was creating problems for human societies. © Jones & Bartlettin regardLearning, to health LLC and illness. A mechanistic © PostmodernismJones & Bartlett is often Learning, considered toLLC have NOT FOR SALE ORapproach DISTRIBUTION is one that focuses on fixing prob- NOTbegun FOR around SALE 1950, OR after DISTRIBUTION the end of World lems as if one is fixing a machine as contrasted War II. However, some people trace its begin- to a humanistic, or holistic, approach, in which nings back to German philosopher Friedrich one readily acknowledges that well-being and Nietzsche in the late 1800s. Pence (2000) de- health occur along a complex continuum and fined postmodernism as “a modern movement some situations© Jones and health & Bartlett problems Learning,cannot in LLCphilosophy and the humanities© that Jones rejects & Bartlett Learning, LLC be predicted,NOT fixed, FORor cured. SALE OR DISTRIBUTIONthe optimistic view that scienceNOT and reason FOR SALE OR DISTRIBUTION will improve humanity; it rejects the notion of sustained progress through reason and the sci- ETHICAL REFLECTION entific method” (p. 43). The postmodern mind is formed by a pluralistic view, or a diversity © JonesIdentify & examplesBartlett of mechanisticLearning, practices LLC in of intellectual and© Jones cultural &influences. Bartlett People Learning, LLC NOT FORhealth SALEcare today. OR DISTRIBUTION who live accordingNOT to FOR a postmodern SALE ORphilos DISTRIBUTION- ophy acknowledge that reality is constantly changing and scientific investigations cannot During the 18th century, David Hume provide one grand theory or correct view of an (1711–1776) proposed an important idea absolute Truth that can guide human behav- © Jones & Bartlettabout Learning, moral reasoning. LLC Hume argued there is © ior,Jones relationships, & Bartlett and life. Learning, Human knowledge LLC NOT FOR SALE ORa distinction DISTRIBUTION between facts and values when NOTis thought FOR insteadSALE toOR be DISTRIBUTIONshaped by multiple moral reasoning is practiced. This fact/value factors, with storytelling and narrative analysis distinction has also been called the is/ought being viewed as core components of knowl- gap. A skeptic, Hume suggested a person edge development. should not acknowledge a fact and then make a value judgment© Jones based &on Bartlett that fact becauseLearning, LLC © Jones & Bartlett Learning, LLC one logicallyNOT cannot FOR take aSALE fact of whatOR isDISTRIBUTION and Care-Based Versus Justice-BasedNOT FOR SALE OR DISTRIBUTION then determine an ethical judgment of what ought to be. If Hume’s position is accepted as Reasoning valid, people should not make assumptions A care approach to moral reasoning is often such as the following: (1) if all dogs have fleas associated with a feminine way of thinking, © Jones(assuming & Bartlett this is a known Learning, fact) and LLC (2) Sara is and a cure approach© Jones is usually & Bartlettassociated withLearning, LLC NOTa FOR dog (a SALEfact), then OR (3) DISTRIBUTIONSara ought not to be al- a masculine, Enlightenment-eraNOT FOR SALE way of OR think DISTRIBUTION- lowed to sleep on the sofa because having fleas ing. In 1981, Lawrence Kohlberg, a psychol- on the sofa is a bad thing (a value statement). ogist, reported his landmark research about

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moral reasoning based on 84 boys he had stud- moral reasoning, there is a pattern of rich and ied for© more Jones than &20 Bartlettyears. Based Learning, on the work LLCinteresting values, perspectives,© Jones and practices & Bartlett Learning, LLC of JeanNOT Piaget, FOR Kohlberg SALE defined OR DISTRIBUTIONsix stages of evident in today’s globally connectedNOT FOR world. SALE OR DISTRIBUTION moral development ranging from childhood to adulthood. Interestingly, Kohlberg did not include any women in his research, but he expected to use his six-stage scale to measure ▸▸ Ethical Theories © Jones &moral Bartlett development Learning, in both males LLC and females. © Jones & Bartlett Learning, LLC NOT FOR SALEWhen OR the DISTRIBUTIONscale was applied to women, andNOT Approaches FOR SALE OR DISTRIBUTION they seemed to score at only the third stage of Normative ethical theories and approaches the sequence, a stage in which Kohlberg de- function as moral guides to answer the ques- scribed morality in terms of interpersonal rela- tions “What ought I do or not do?” and “How tionships and helping others. Kohlberg viewed should I be?” A theory can provide individuals © Jones & Bartlett Learning,this third stageLLC of development as somewhat© Jones with & guidance Bartlett in Learning,moral thinking LLC and reason- NOT FOR SALE OR DISTRIBUTIONdeficient in regard to mature moral reasoning.NOT FORing asSALE well as OR justification DISTRIBUTION for moral actions. Because of Kohlberg’s exclusion of females in The following theories and approaches are not his research and his negative view of this third all inclusive, but they represent some of the stage, Carol Gilligan, one of Kohlberg’s associ- most popular. ates, raised the concern of gender bias. Gilli- gan, in© turn,Jones published & Bartlett an influential Learning, book in LLC © Jones & Bartlett Learning, LLC 1982,NOT In a Different FOR SALEVoice, in ORwhich DISTRIBUTION she argued Western Ethics NOT FOR SALE OR DISTRIBUTION that women’s moral reasoning is different but not deficient. The distinction usually made Religion and Western Ethics between moral reasoning as it is suggested by A discussion of Western ethics systems likely Kohlberg and Gilligan is that Kohlberg’s is a prompts some people to want to include © Jones &male-oriented Bartlett Learning, ethic of justice LLC and Gilligan’s is monotheistic© Jones Western & Bartlettreligious Learning,traditions, LLC NOT FORa SALEmore feminine OR DISTRIBUTION ethic of care (covered later in such as Judaism,NOT FOR Christianity, SALE and OR Islam. DISTRIBUTION Mo- this chapter). rality in each of these religions is based on sacred texts—the first five books of the Old Testament of the Bible (Torah) in Judaism, the Learning from History Old and especially the New Testament of the © Jones & Bartlett Learning,Often, it is LLC only in hindsight that people© are Jones Bible & inBartlett Christianity, Learning, and the Qur’an LLC (Koran) NOT FOR SALE OR DISTRIBUTIONable to analyze a historical era in which thereNOT FORgiven SALE by Allah OR to theDISTRIBUTION Prophet Muhammad in is a converging of norms and beliefs held in Islam. Pleasing God, according to sacred laws high esteem or valued by large groups within a and traditions, dominates prescribed moral society. Like the overlapping approaches used behavior in each of these religious groups. In by some ethical objectivists, the influences of addition to sacred scripture, there are histor- historical© Jones eras also & build Bartlett upon each Learning, other and LLCical figures who heavily influenced© Jones religious & Bartlett Learning, LLC often NOTare hard FOR to separate. SALE Christians OR DISTRIBUTION still base ethical systems, for example,NOT the FOR Catholic SALE OR DISTRIBUTION much of their ethical reasoning on the phil- saints Augustine and Aquinas and the medie- osophy generated during the Middle Ages. val Jewish philosopher Maimonides. At the same time, it is evident that individ- The politically, socially, and intellectually ualistic ways of thinking that were popular focused ancient Greeks provided the most de- © Jones &during Bartlett the EnlightenmentLearning, LLCremain popular veloped ©system Jones of ethics & Bartlett in the Western Learning, world LLC NOT FORtoday SALE in Western OR DISTRIBUTION societies because autonomy until theNOT Middle FOR Ages whenSALE religious OR DISTRIBUTION doctrine (self-direction) is so highly valued. Because became the primary focus. Then, as people varied historical influences have affected moved into the Enlightenment period and

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again viewed human intellect as being trust- well. If one needs the services of a knife, it is worthy for providing© Jones moral & Bartlett guidance, Learning,secular probably LLC safe to assume a knife ©that Jones exhibits & Bartlett Learning, LLC systems of ethicsNOT overtookFOR SALE religious OR systems. DISTRIBUTION excellence in cutting would be theNOT type of FOR knife SALE OR DISTRIBUTION Today, among many people, the lines between one would want to use; most people want to sacred and secular ethics are blurred. It is a use a knife that accomplishes its purpose in the key point of understanding ethics, however, best way possible. that in a post-Enlightenment world, ethics For humans, virtue ethics addresses the © Jonesfalls under & Bartlett the umbrella Learning, of philosophy LLC rather question “What© sort Jones of person & Bartlett must I be Learning, to LLC NOTthan FOR religion. SALE The OR ethical DISTRIBUTION systems discussed in be an excellent NOTperson?” FOR rather SALE than “What OR DISTRIBUTIONis this chapter are those considered to be classic my duty?” Virtues for humans are habitual, theories and approaches in Western ethical though not routinized, excellent traits inten- philosophy, though some of them do stem tionally developed throughout one’s life. An- from religious traditions. nas (2011) outlined a description of how to © Jones & Bartlett Learning, LLC © spotJones virtue. & In Bartlett regard to Learning,a person, a virtue LLC is a NOT FOR SALE OR DISTRIBUTION NOT“lasting FOR feature” SALE (loc. OR 138); DISTRIBUTION it is “active” and de- FOCUS FOR DEBATE velops “through selective response to circumstances” (loc. 142). Virtue “persists through Does a person need to be religious to be challenges and difficulties, and it is strength- moral? For example, can an atheist be moral? ened or weakened by . . . responses” (loc. 142). Can or should© Jonesethics be separated& Bartlett from Learning,“A LLCvirtue is also a reliable disposition© Jones. . . it is no & Bartlett Learning, LLC religion? DefendNOT your FOR positions. SALE OR DISTRIBUTIONaccident” (loc. 146). NOT FOR SALE OR DISTRIBUTION A person of virtue, consistent with Aris- totle’s way of thinking, is a person who is an Virtue Ethics excellent friend to other people, an excellent thinker, and an excellent citizen of a commun- Watch your thoughts; they become words. © Jones & Bartlett Learning, LLC ity. Aristotle’s (trans.© Jones 2002) approach& Bartlett to virtue Learning, LLC Watch your words; they become actions. NOT FOR SALE OR DISTRIBUTION ethics is groundedNOT in twoFOR categories SALE ofOR excel DISTRIBUTION- Watch your actions; they become habits. lence: intellectual virtues and character, or Watch your habits; they become character. moral, virtues. According to Aristotle, “the in- Watch your character; it becomes your destiny. tellectual sort [of virtue] mostly . . . comes into —Various attributions existence and increases as a result of teach- © Jones & Bartlett Learning, LLCbut author unknown © ingJones (which & is Bartlett why it requires Learning, experience LLC and NOT FOR SALE OR DISTRIBUTION NOTtime), FOR whereas SALE excellence OR DISTRIBUTION of character results Rather than centering on what is right or wrong from habituation” (p. 111). The habituation in terms of one’s duties or the consequences of Aristotle had in mind is an intelligent, mind- one’s actions, the excellence of one’s character ful attention to excellent habits rather than a and considerations of what sort of person one thoughtless routinization of behaviors. wants or ought© Jonesto be are emphasized& Bartlett in Learning,virtue LLCThough Aristotle (trans. 2002)© Jones divided & Bartlett Learning, LLC ethics. SinceNOT the time FOR of PlatoSALE and OR Aristotle, DISTRIBUTION virtues into two kinds—those of NOTthe intellect FOR SALE OR DISTRIBUTION virtues, called arête in Greek, have referred to and those of character—the two categories of excellences in regard to people or objects being virtues cannot be distinctly separated. Aristotle the best they can be in accordance with their proposed “it is not possible to possess excel- purpose. As the ancient Greeks originally con- lence in the primary sense [that is, having excel- © Jonesceived & the Bartlett concept, evenLearning, an inanimate LLC object lence of character]© Jones without &wisdom, Bartlett nor toLearning, be LLC NOTcan FOR have SALE virtue. ORFor example, DISTRIBUTION the purpose of wise without excellenceNOT FOR of character” SALE (p. OR 189). DISTRIBUTION a knife is to cut, so arête in regard to a knife Aristotle realized good things taken to means the knife has a sharp edge and cuts very an extreme could become bad. He therefore

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proposed that there is a Golden Mean in ways usefulness of virtues, his approach to ethics is of being.© Jones Most virtues & Bartlett are considered Learning, to exist LLCalso associated with utilitarianism,© Jones which & Bartlett is Learning, LLC as a moderateNOT FOR way ofSALE being between OR DISTRIBUTION two kinds discussed later in this chapter.NOT Hume’sFOR SALEphil- OR DISTRIBUTION of vices or faults: the extremes of excess at osophy of ethics is based on emotion as the one end and deficiency at the other. For in- primary human motivator for admirable stance, Aristotle named courage as a virtue, behavior rather than motivation by reason. but the extremes of rashness at one end of a However, Hume did not propose that ethics © Jones &continuum Bartlett and Learning, cowardice at LLC the other end of is based ©merely Jones on personal& Bartlett opinion. Learning, Virtu- LLC NOT FORthe SALE same continuumOR DISTRIBUTION are its related vices. An- ous behaviorNOT is FORvalidated SALE by the OR consensus DISTRIBUTION of other example is the virtue of truthfulness, members of communities according to what is which is the mean between boastfulness and useful for a community’s well-being. self-deprecation. The mean for each virtue is A different and more radical view of virtue unique for each type of virtue and situation; in ethics is based on the philosophy of Nietzsche. © Jones & Bartlett Learning,other words, LLC the mean is not a mathematical© Jones Rather & Bartlett than viewing Learning, people as LLC caring, sym- NOT FOR SALE OR DISTRIBUTIONaverage. NOT FORpathetic SALE beings, OR Nietzsche DISTRIBUTION proposed the best Other examples of virtues include benev- character for people to cultivate is grounded olence, compassion, fidelity, generosity, and in a will to power. Nietzsche believed the will patience. Plato designated the four virtues of to power rightly should motivate people to prudence (wisdom), fortitude (courage), tem- achieve dominance in the world. Nietzsche perance© Jones(moderation), & Bartlett and justice Learning, as cardinal LLCpraised strength as virtuous,© whereas Jones so-called & Bartlett Learning, LLC virtues,NOT meaning FOR all SALE other ORvirtues DISTRIBUTION hinge on feminine virtues, such as caringNOT and FOR kindness, SALE OR DISTRIBUTION these four primary virtues. Prudence corre- he considered to be signs of weakness. This sponds to Plato’s idea of the Faculty of Reason, means, according to Nietzsche, that virtue is fortitude corresponds to the Faculty of Spirit, consistent with hierarchical power or power and temperance corresponds to the Faculty of over other people, which makes the Christian © Jones &Appetite; Bartlett the Learning,virtue of justice LLC is an umbrella virtue of© humility Jones a vice. & Bartlett It is believed Learning, another LLC NOT FORvirtue SALE encompassing OR DISTRIBUTION and tying together the German,NOT Adolf FORHitler, adoptedSALE theOR philosophy DISTRIBUTION other three. of Nietzsche as his worldview. Though Ni- The ancient Greeks are most frequently etzsche is a well-known and important person associated with virtue ethics, but other philos- in the history of philosophy, his approach to ophers and ethicists have also proposed views virtue ethics has little place in nursing ethics. © Jones & Bartlett Learning,about virtues. LLC The Scottish philosopher David© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONHume (1711–1776) and the German philosNOT- FOR SALE OR DISTRIBUTION opher Friedrich Nietzsche (1844–1900) each ETHICAL REFLECTION proposed an interesting philosophy of virtue ethics that differs from the philosophies of the Partner with a colleague, and list several real-life examples related to each line of the Greeks, though Hume’s and Nietzsche’s are not © Jones & Bartlett Learning, LLC quotation at the beginning ©of theJones “Virtue & Bartlett Learning, LLC the only other approaches to virtue ethics. Ethics” section. Hume,NOT whoseFOR approachSALE OR is used DISTRIBUTION by some NOT FOR SALE OR DISTRIBUTION feminist philosophers, believed virtues flow from a natural human tendency to be sym- Although virtue ethics is popular again pathetic or benevolent toward other people. today, over the years interest in this ethical ap- Virtues are human character traits admired by proach experienced a significant decline among © Jones &most Bartlett people and Learning, judged to beLLC generally pleas- Western ©philosophers Jones & and Bartlett nurses (MacIntyre,Learning, LLC NOT FORing SALE as well OR as being DISTRIBUTION useful to other people, use- 1984; Tschudin,NOT FOR 2003). SALE Many Western OR DISTRIBUTION philos- ful to oneself, or useful to both other people ophers lost interest in the virtues when they and to oneself. Because of Hume’s focus on the became entrenched in the schools of thought

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popularized during the Enlightenment era Greeks. In fact, natural law theory is complex, that emphasized© Jones individualism & Bartlett and autonomy Learning, and LLC attempting to present its essence© Jones would be & Bartlett Learning, LLC (MacIntyre, NOT1984). FOR SALE OR DISTRIBUTIONto oversimplify the theory (Buckle,NOT 1993). FOR Even SALE OR DISTRIBUTION Over time, nurses concluded it was not the terms nature and natural are ambiguous. helpful professionally to follow the tradition of Aristotle’s conception of natural law the- Florence Nightingale because her view of vir- ory is a universal type of justice grounded tues in nursing includes a virtue of obedience in the laws of nature rather than human law. © Jones(Sellman, & Bartlett1997). However, Learning, Nightingale’s LLC valu- Most modern versions© Jones of natural& Bartlett law theory Learning, LLC NOTing FOR of obedience SALE needsOR DISTRIBUTIONto be viewed within the have their basisNOT in the FORreligious SALE philosophy OR DISTRIBUTIONof context of the time in which she lived. Also, Saint Thomas Aquinas. Because he believed Nightingale’s liberal education in Greek phil- God created everything and implanted all osophy may have influenced her use of the things with purpose and order in concert with virtue of obedience to reflect her belief in the His will, Aquinas deduced that people could © Jones & Bartlettvalue Learning, of practical LLCwisdom as conceived by Ar- © investigateJones & nature Bartlett and find Learning, God’s expectations LLC NOT FOR SALE ORistotle DISTRIBUTION (LeVasseur, 1998; Sellman, 1997). In NOTthere. FOR Consequently, SALE OR people DISTRIBUTION who use natural connecting obedience to practical wisdom, law theory contend the rightness of actions some nurses now understand Nightingale’s is self-evident because morality is inherently conception as approaching something akin to implanted in the order of nature and not re- intelligent obedience rather than a subservient vealed through customs and preferences. To- allegiance of© nurses Jones to physicians. & Bartlett Learning,day, LLC natural law theory is the basis© for Jones religious & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONprohibitions against acts some peopleNOT consider FOR SALE OR DISTRIBUTION FOCUS FOR DEBATE unnatural, such as homosexuality and the use of birth control. Can a limited set of virtues be identified as Though natural law theory and divine command theory sometimes are confused, © Jonesessential & Bartlett for members Learning, of the nursing profession? LLC © Jones & Bartlett Learning, LLC Which virtues are most important in nursing? they have a fundamental difference. According NOT FORSearch SALEthe American OR Nurses DISTRIBUTION Association’s to divine commandNOT theory, FOR an SALE action ORis good DISTRIBUTION (2015) Code of Ethics for Nurses with Interpretive because a divine being, such as God, com- Statements, and identify a list of virtues mands it, whereas with natural law theory, a discussed directly or indirectly in the document. divine being commands an action because it is Remember, virtues are excellent qualities moral irrespective of said divine being. © Jones & Bartlett ofLearning, character, such LLCas being compassionate, © Jones & Bartlett Learning, LLC courageous, truthful, and humble. NOT FOR SALE OR DISTRIBUTION NOTDeontology FOR SALE OR DISTRIBUTION Natural Law Theory Deontology, literally the study of duty, is an approach to ethics focused on duties and rules. There is in fact a true law—namely, right reason— The most influential philosopher associated which is in accordance with nature, applies to © Jones & Bartlett Learning,with LLC the deontological way of thinking© Jones was Im -& Bartlett Learning, LLC all men, and is unchangeable and eternal. By manuel Kant (1724–1804). Kant defined a per- its commandsNOT this FORlaw summons SALE menOR toDISTRIBUTION the NOT FOR SALE OR DISTRIBUTION son as a rational, autonomous (self-directed) performance of their duties; by its prohibitions it being with the ability to know universal, ob- restrains them from doing wrong. jective moral laws and the freedom to decide to —Marcus Tullius Cicero, act morally. Kantian deontology prescribes © Jones & Bartlett Learning,The Republic LLC (51 BCE) that each rational© Jonesbeing is ethically& Bartlett bound Learning, to LLC NOT FOR SALE OR DISTRIBUTION act only from aNOT sense FORof duty; SALE when decidingOR DISTRIBUTION Natural law theory has a long and varied hist- how to act, the consequences of one’s actions ory, dating back to the work of the ancient are considered to be irrelevant.

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According to Kant, it is only through du- for instance, if I want to become a nurse, then I tiful actions© Jones that &people Bartlett can be Learning, moral. Even LLChave to study during nursing© school.Jones & Bartlett Learning, LLC whenNOT individuals FOR do SALE not want OR to act DISTRIBUTION from duty, Where moral actions areNOT concerned, FOR SALEKant OR DISTRIBUTION Kant believed they are ethically bound to do so. believed duties and laws are absolute and un- In fact, Kant asserted that having one’s actions conditional. Kant proposed that people ought motivated by duty is superior to acting from to follow a universal, unconditional frame- a motivation of love. Because rational choice work of maxims, or rules, as a guide to know © Jones &is withinBartlett one’s Learning, control as compared LLC to one’s the rightness© Jones of actions & andBartlett one’s moral Learning, duties. LLC NOT FORtenuous SALE control OR DISTRIBUTIONover personal emotions, Kant He calledNOT these FOR absolute SALE and ORunconditional DISTRIBUTION was convinced that only reason, not emotion, duties categorical imperatives. When de- is sufficient to lead a person to moral actions. ciding about matters of ethics, one should act Kant believed people are ends in them- according to a categorical imperative and ask selves and should be treated accordingly. Each the question “If I perform this action, could I © Jones & Bartlett Learning,autonomous, LLC self-directed person has dignity© Jones will & that Bartlett it should Learning, become a universal LLC law for NOT FOR SALE OR DISTRIBUTIONand is due respect, and one should neverNOT act FOReveryone SALE to act OR in DISTRIBUTIONthe same way?” No action in ways that involve using other people as a can ever be judged as right, according to Kant, means to one’s personal ends. In fact, when if it is not reasonable that the action could be people use others as a means to an end, even used as a binding, ethical law for all people. if they believe they are attempting to reach For example, Kant’s ethics imposes the cate- ethical© goals,Jones Kant & believedBartlett people Learning, could be LLCgorical imperative that one© shouldJones never & Bartlett tell Learning, LLC harmed.NOT An exampleFOR SALE of this todayOR DISTRIBUTIONis the failure a lie because a person cannotNOT rationally FOR SALEwish OR DISTRIBUTION to obtain informed consent from a research that all people should be able to pick and participant even when the researcher stead- choose when they have permission not to be fastly believes the research will be beneficial to truthful. Another example of a categorical im- the participant. perative is that suicide is never acceptable. A © Jones & Bartlett Learning, LLC person, when© Jones committing & Bartlett suicide, shouldLearning, not LLC NOT FOR SALE OR DISTRIBUTION rationallyNOT wish FORthat all SALEpeople should OR DISTRIBUTION feel free ETHICAL REFLECTION to commit suicide, or the world would become chaotic. Review the American Nurses Association’s (2015) Code of Ethics for Nurses with Interpretive © Jones & Bartlett Learning,Statements LLC. Is the code based primarily on a© JonesConsequentialism & Bartlett Learning, LLC deontological approach to nursing? Is it based Consequentialists, as distinguished from de- NOT FOR SALE OR DISTRIBUTIONprimarily on a virtue ethics approach? Both?NOT FOR SALE OR DISTRIBUTION Discuss specific examples in the code that ontologists, do consider consequences to be support your answer. an important indication of the moral value of one’s actions. Utilitarianism is the most well-known consequentialist theory of ethics. Kant© Jones identified & rulesBartlett to guide Learning, people in LLCUtilitarianism means actions© Jones are judged & Bartlett by Learning, LLC thinkingNOT about FOR their SALE obligations. OR DISTRIBUTIONHe drew a their utility; that is, they areNOT evaluated FOR accord SALE- OR DISTRIBUTION distinction between two types of duties or ob- ing to the usefulness of their consequences. ligations: the hypothetical imperative and the When people use the theory of utilitarianism categorical imperative. Hypothetical impera- as the basis for ethical behavior, they attempt to tives are optional duties, or rules, people ought promote the greatest good (happiness or plea- © Jones &to Bartlettobserve or Learning,follow if certain LLC ends are to be sure) and© to Jones produce &the Bartlett least amount Learning, of harm LLC NOT FORachieved. SALE HypotheticalOR DISTRIBUTION imperatives are some- (unhappiness,NOT suffering,FOR SALE or pain) OR possible DISTRIBUTION in a times called if–then imperatives, which means situation. In other words, utilitarians believe it they involve conditional, or optional, actions; is useful to society to achieve the greatest good

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for the greatest number of people who may be protected from diseases, and the consequence affected by an© action.Jones & Bartlett Learning,is thatLLC people are happier because© they Jones are free & Bartlett Learning, LLC British NOTphilosopher FOR SALEJeremy ORBentham DISTRIBUTION of diseases. People who use Mill’s NOTform of FOR util- SALE OR DISTRIBUTION (1748–1832), a contemporary and associate itarian theory often can use widely supported of Florence Nightingale’s father, was an early traditions to guide them in deciding about rules promoter of the principle of utilitarianism. and behaviors that probably will produce the During Bentham’s life, British society func- best consequences for the most people, such © Jonestioned &according Bartlett to aristocratic Learning, privilege. LLC Poor as the maxim that© Jonesstealing is& wrong. Bartlett Through Learning, LLC NOTpeople FOR were SALE mistreated OR DISTRIBUTION by people in the upper experience, humansNOT generally FOR SALE have identified OR DISTRIBUTION classes and given no choice other than to work behaviors that produce the most happiness or long hours in deplorable conditions. Bentham unhappiness for society as a whole. tried to develop a theory to achieve a fair dis- Over time, people who subscribe to a tribution of pleasure among all British citi- theory of utilitarianism have divided them- © Jones & Bartlettzens. Learning, He went so farLLC as to develop a systematic © selvesJones into & subgroups.Bartlett Learning,Two main types LLC of NOT FOR SALE ORdecision-making DISTRIBUTION method using mathematical NOTutilitarianism FOR SALE have developedOR DISTRIBUTION over the years: calculations. Bentham’s method was designed rule utilitarianism and act utilitarianism. Rule to determine ways to allocate pleasure and di- utilitarians believe there are certain rules— minish pain by using the measures of intensity such as do not kill, do not break promises, and and duration. This approach to utilitarianism do not lie—that, when followed, usually create has been criticized© Jones because & BartlettBentham equatedLearning, the LLC best consequences for the most© Jones people. & Bartlett Learning, LLC all types of pleasureNOT FOR as being SALE equal. OR DISTRIBUTIONBased on this definition, someoneNOT might FOR ask, SALE OR DISTRIBUTION John Stuart Mill (1806–1873), another “What is the difference between rule utilitar- Englishman, challenged Bentham’s views. ianism and deontology?” The answer is that Mill clearly pointed out that particular expe- all utilitarian theories of ethics, whether based riences of pleasure and happiness do have dif- on rules or individual actions, are predicated © Jonesferent qualities& Bartlett and different Learning, situations LLC do not on achieving good© Jones consequences & Bartlett for the most Learning, LLC NOTnecessarily FOR SALE produce OR equal DISTRIBUTION consequences. For people. Deontologists,NOT FOR on theSALE other OR hand, DISTRIBUTION example, Mill stated that higher intellectual make decisions based on right duty rather than pleasures may be differentiated from lower on right consequences. physical pleasures. The higher pleasures, such Act utilitarians believe each action in as enjoying a work of art or a scholarly book, a particular circumstance should be chosen © Jones & Bartlettare Learning, considered betterLLC because only human © basedJones on &its Bartlettlikely good Learning, consequences LLC rather NOT FOR SALE ORbeings, DISTRIBUTION not other animals, possess the mental NOTthan FOR on following SALE an OR inherently DISTRIBUTION moral, univer- faculties to enjoy this higher level of happiness. sal rule. The utility of each action in achieving According to Mill, happiness and pleasure the most happiness is the aim of act utilitari- are measured by quality and not quantity (dur- ans, whereas rule utilitarians are willing to ac- ation or intensity). In making these distinctions cept causing more suffering than happiness in between higher© Jones and lower & levelsBartlett of happiness Learning, a particular LLC situation to avoid violating© Jones a gen -& Bartlett Learning, LLC and pleasure,NOT Mill’s philosophyFOR SALE is focused OR DISTRIBUTIONmore eralized rule. For example, promiseNOT breaking FOR is SALE OR DISTRIBUTION on ethics than politics and social utility. permitted according to act utilitarianism if the Mill believed communities usually agree consequences of the action (breaking a prom- about what is good and things that best promote ise) cause more happiness than suffering in a the well-being of most people. An example of particular situation. In the same situation, a © Jonesan application & Bartlett of Mill’s Learning, utilitarianism LLC is the use rule utilitarian ©would Jones say a &promise Bartlett should Learning, be LLC NOTof FOR mandatory SALE vaccinationOR DISTRIBUTION laws—indiv idual upheld because,NOT in most FOR cases, SALE promise OR keep DISTRIBUTION- liberties are limited so the larger society is ing causes more happiness than suffering.

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Principlism LEGAL© Jones PERSPECTIVE & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Principles NOT FOR SALE OR DISTRIBUTION are rule-based NOTcriteria FORfor conduct SALE OR DISTRIBUTION Conduct a search about the theory of that naturally flow from the identification of ob- utilitarianism; infectious diseases, such as ligations and duties. Consequently, the theory Mycobacterium tuberculosis; and the law. of deontology is a forerunner of the approach Discuss your findings. of principlism. Principles usually are reducible © Jones & Bartlett Learning, LLC to concepts© Jonesor statements, & Bartlett such as the Learning, principle LLC NOT FOR SALE OR DISTRIBUTION of beneficenceNOT orFOR respect SALE for a person’sOR DISTRIBUTION autonomy. Often, principles are used as the basis for Prima Facie Rights ethically related documents, such as documents reflecting positions about human rights. Exam- The term prima facie means on one’s first ples of principle-based documents include the impression, or on the face of things; that is, American Hospital Association’s (2003) The © Jones & Bartlett Learning,something LLC is accepted as correct until or© un Jones- & Bartlett Learning, LLC Patient Care Partnership and the Universal Dec- NOT FOR SALE OR DISTRIBUTIONless it is shown to be otherwise. For example,NOT FOR SALE OR DISTRIBUTION laration of Human Rights, formulated in 1948 promise keeping is considered an accepted by the United Nations. Principlism is discussed ethical rule. However, if a nurse promised her in more detail in Chapter 2. spouse she would be on time for dinner but, as she was about to leave the hospital, she was told the© Jonesnurse replacing & Bartlett her would Learning, be late for LLCCasuistry © Jones & Bartlett Learning, LLC work,NOT it is expected FOR thatSALE the nurseOR wouldDISTRIBUTION break Casuistry is an approach NOTto ethics FOR grounded SALE OR DISTRIBUTION her promise to be on time for dinner so she in Judeo-Christian history. When people use could attend to her patients until the other casuistry, they make decisions inductively nurse arrives. based on individual cases. The analysis and Prima facie ethics is associated with the evaluation of strongly similar or outstanding © Jones &philosopher Bartlett Sir Learning, William David LLC Ross (1877– cases (i.e.,© paradigmJones &cases) Bartlett provides Learning, guidance LLC NOT FOR1971) SALE and ORhis 1930DISTRIBUTION book, The Right and the in ethicalNOT decision FOR making. SALE A paradigm OR DISTRIBUTION case is Good. Ross is called an ethical intuitionist a benchmark, or landmark, case against which because he believed certain things are intrin- decisions in similar cases are compared and sically good and self-evidently true. Ross un- that provides guidance in similar cases. derstood ethics to suggest that certain acts are When people use casuistry, their ethical de- © Jones & Bartlett Learning,prima facie LLC good—keeping promises, repaying© Jones cision & Bartlettmaking begins Learning, as an inductive, LLC bottom- NOT FOR SALE OR DISTRIBUTIONkindnesses, helping others, and preventingNOT dis- FORup approach SALE inOR considering DISTRIBUTION the details of spe- tress. However, when these prima facie good cific cases rather than beginning from the top actions conflict, one has to decide where one’s down and applying absolute rules and prin- actual duty lies. Ross conceded that human ciples. Long ago, Jewish people often tried to knowledge is imperfect and the best people sort out the relevance of sacred laws in specific can expect© Jones to do is & use Bartlett their imperfect Learning, knowl- LLCsituations in ways that were© practical Jones and & caseBartlett Learning, LLC edge toNOT assess FOR the context SALE of eachOR situation DISTRIBUTION and based rather than absoluteNOT and inflexibly FOR SALE rule OR DISTRIBUTION make an informed judgment, although they based. In Catholic history, the practice of people are uncertain about the correctness of their individually confessing their sins to priests to choices. Ross’s approach to ethics has quite a receive absolution reflects the use of casuistry. bit of relevance for nurses who frequently must Based on the confessor’s specific case (i.e., the © Jones &make Bartlett quick determinations Learning, LLCof how to priori- circumstances© Jones surrounding & Bartlett the occasion Learning, of sin- LLC NOT FORtize SALE important OR actionsDISTRIBUTION that can cause distress ning) a personNOT FORreceives SALE from the OR priest DISTRIBUTION a per- for one person while helping another. sonal penance that is required for absolution.

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LEGAL PERSPECTIVE© Jones & Bartlett Learning, BOXLLC 1-1 Narrative Learning © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Search the internet for information on the 1. Divide into small groups. 1986 Florida legal case Corbett v. D’Alessandro. 2. Choose a children’s book from the list How is the final legal decision in this case below or another similar type of short related to the ethical approach of casuistry children’s book. © Jonesand the& laterBartlett case of SchindlerLearning, v. Schiavo LLC? 3. Read the© book, Jones and as &a g roup,Bartlett apply Learning, LLC NOT FOR SALE OR DISTRIBUTION the book’sNOT message(s) FOR to SALE nursing OR DISTRIBUTION practice. Today, casuistry is often the method used 4. Share your application with other by healthcare ethics committees to analyze groups. You might want to develop the ethical issues surrounding specific patient a creative display or activity to help © Jones & Bartlettcases. Learning, The Four Topics LLC Method of ethical deci- © Jonesillustrate & Bartlett your points. Learning, LLC Books: NOT FOR SALE ORsion DISTRIBUTIONmaking is based on a casuistry approach NOT FOR SALE OR DISTRIBUTION (see Chapter 2). ■■ The Little Engine That Could (Original Classic Edition) ■■ The Juice Box Bully Narrative Ethics ■■ Have You Filled a Bucket Today? ■ Because it is© a Jones story-based & Bartlett approach, Learning,narra- LLC■ Lacey Walker Nonstop Talker © Jones & Bartlett Learning, LLC tive ethics has similarities to casuistry. Also, ■■ The Fall of Freddie the Leaf according toNOT one of FOR the foremost SALE modern-day OR DISTRIBUTION ■■ What If Everybody Did That? NOT FOR SALE OR DISTRIBUTION ■ virtue ethicists, Alasdair MacIntyre, narrative ■ Thanks for the Feedback, I Think ■■ Stone Soup thinking and virtue ethics are closely con- ■■ Old Turtle nected. Both narrative ethics and virtue ethics ■■ The Three Questions © Jonesare firmly & Bartlett embedded Learning, in human relationships. LLC © Jones & Bartlett Learning, LLC MacIntyre (1984) proposed that a human is NOT“essentially FOR SALE a story-telling OR DISTRIBUTION animal”; a person is NOT FOR SALE OR DISTRIBUTION “a teller of stories that aspire to truth” (p. 216). stories evolve, are constructed, and can be Narratives, such as novels and literary stor- changed. Narratives are stories being lived, ies, change us in remarkable ways (Murray, read, watched, heard, discussed, analyzed, or compared. © Jones & Bartlett1997). Learning, From childhood, LLC most people obtain © Jones & Bartlett Learning, LLC moral education about character development Narratives are context or situation bound. NOT FOR SALE ORfrom DISTRIBUTION stories, such as fairy tales and fables (see NOTFor peopleFOR SALEto decide OR what DISTRIBUTION they should do in BOX 1-1). When using a narrative approach particular circumstances, they may first iden- to ethics, nurses are open to learning from a tify how their moral character and actions fit storied, nuanced view of life; that is, they are within the greater stories of their culture. Peo- sensitive to how personal and community ple are situated within their personal life nar- © Jones & Bartlett Learning,ratives, LLC and their stories intersect ©with Jones and are & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONinterwoven into the narratives of NOTother people FOR SALE OR DISTRIBUTION ETHICAL REFLECTION with whom they interact. Nurses who use narrative ethics are aware that there is more to a patient’s story than is known or discussed Discuss several specific stories in books and among healthcare providers. People are not © Jonesmovies & thatBartlett have affected Learning, your moral LLC views or © Jones & Bartlett Learning, LLC made an impact on your way of thinking solitary creatures, and as they interact with NOT FORethically. SALE What are OR the DISTRIBUTIONthemes and symbols other people andNOT their FORenvironment, SALE they OR must DISTRIBUTION used in the stories? make choices about what they believe and how they will act. They create their own stories.

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When using a narrative approach to eth- natural, and inevitable (thereby ics, nurses© Jones realize that& Bartlett individual Learning,human stories LLC heading off potential© Jones challenges & Bartlett to Learning, LLC are beingNOT constantly FOR SALE constructed OR inDISTRIBUTION relation to the system) is throughNOT FORthe dissemi SALE- OR DISTRIBUTION the stories of a greater community of people. nation of dominant ideology In nursing, a good example of narrative ethics 3. That critical theory attempts to un- involves nurses with sensitive awareness en- derstand this state of affairs as a nec- countering each patient’s unfolding life story essary prelude to changing it (p. viii) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in everyday practice. These nurses know that One critical theory widely used by nurses NOT FORtheir SALE actions OR while DISTRIBUTION caring for patients influence is a feministNOT approach FOR SALE to ethics. OR Under DISTRIBUTION this the unfolding stories of those patients in both broad feminist approach is the ethic of care large and small ways. A “narrative approach to originating from the Gilligan–Kohlberg de- bioethics focuses on the patients themselves: bate discussed earlier in this chapter. these are the moral agents who enact choices” © Jones & Bartlett Learning,(Charon & LLC Montello, 2002, p. xi). In narrative© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONethics, patients’ and nurses’ stories matter; howNOT- FORFeminist SALE Ethics OR DISTRIBUTION ever, no one story should be accepted without According to Tong (1997), “to a greater or critical reflection. lesser degree, all feminist approaches to ethics are filtered through the lens of gender” (p. 37). Critical© Jones Theory & Bartlett Learning, LLCThis means feminist ethics© is Jones specifically & Bartlett fo- Learning, LLC CriticalNOT theory FOR, sometimes SALE OR referred DISTRIBUTION to as cused on evaluating ethicallyNOT related FOR situations SALE OR DISTRIBUTION critical social theory, is a broad term iden- in terms of how these situations affect women. tifying theories and worldviews addressing the The concept of feminist ethics tends to have a domination perpetrated by specific powerful political connotation and addresses the pat- groups of people and the resulting oppression terns of women’s oppression as this oppression © Jones &of otherBartlett specific Learning, groups of people. LLC There are a is perpetrated© Jones by dominant & Bartlett social groups,Learning, es- LLC NOT FORnumber SALE of OR critical DISTRIBUTION theories included under one pecially sociallyNOT FOR powerful SALE men. OR DISTRIBUTION broad heading. In citing the group of German philosophers who originated the concept of Ethic of Care. An ethic of care is grounded in critical theory, Bohman (2005) stated that crit- the moral experiences of women and feminist ical theories can be distinguished from tradi- ethics. It evolved into an approach to ethics tional theories because the purpose of critical © Jones & Bartlett Learning, LLC © Jonesthat & gained Bartlett popularity Learning, because of LLC the Gilligan– theories is to promote human emancipation. Kohlberg debate about the differences in NOT FOR SALE OR DISTRIBUTIONSpecifically, the purpose of using criticalNOT the- FOR SALE OR DISTRIBUTION women’s and men’s approaches to moral rea- ories is “to liberate human beings from the cir- soning. Rather than being based on duty, fair- cumstances that enslave them” (Horkheimer, ness, impartiality, or objective principles (ethic as cited in Bohman, 2005, para. 1). According of justice) similar to the values popularized to Brookfield (2005), there are three core as- © Jones & Bartlett Learning, LLCduring the Enlightenment© era, Jones an ethic & Bartlett of Learning, LLC sumptions in critical theory that explain how NOT FOR SALE OR DISTRIBUTIONcare emphasizes the importanceNOT ofFOR tradition SALE- OR DISTRIBUTION the world is organized: ally feminine traits, such as love, compassion, 1. That apparently open, Western de- sympathy, and concern about human well- mocracies are actually highly un- being. The natural partiality in how people equal societies in which economic care more about some people than others is © Jones & Bartlettinequity, Learning, racism, andLLC class discrim- acknowledged© Jones as acceptable & Bartlett in an ethic Learning, of care. LLC NOT FOR SALE ORination DISTRIBUTION are empirical realities Also, theNOT role of FOR emotions SALE in moral OR reasoningDISTRIBUTION 2. That the way this state of affairs is and behavior is accepted as a necessary and reproduced and seems to be normal, natural complement to rational thinking. This

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position distinguishes an ethic of care from an focused on individuals’ innate but unrecog- ethic of justice© Jonesand duty-based & Bartlett ethics that Learning, em- nized LLC perfection and the ability ©to Jonestranscend & Bartlett Learning, LLC phasize the NOTpreeminence FOR ofSALE reason OR and DISTRIBUTIONmin- earthly suffering and dissatisfactionNOT through FOR SALE OR DISTRIBUTION imize the importance of emotion in guiding one’s own abilities. Therefore, Eastern ethics is moral reasoning and the moral nature of one’s not imposed from outside of a person but in- relationships. stead is imposed from within oneself. Eastern ethics tends to be a discipline of training the © Jones & Bartlett Learning, LLC mind and includes© Jones the concept & Bartlett that unethical Learning, LLC NOT FORFOCUS SALE FOR DEBATE OR DISTRIBUTION behavior leads toNOT karmic FOR results SALE (i.e., the OR qual DISTRIBUTION- ity of one’s actions results in fair consequences Is caring a virtue? according to the universal law of cause and ef- fect). The four largest Eastern ethical systems, which contain myriad variations and now ex- © Jones & Bartlett Learning, LLC © istJones in a number & Bartlett of countries, Learning, are Indian LLC ethics NOT FOR SALE ORETHICAL DISTRIBUTION REFLECTION NOT(Hinduism FOR andSALE Buddhism) OR DISTRIBUTION and Chinese ethics (Taoism and Confucianism). Review the theories developed by nurse theorists. Which ones are based on an ethic of care? Indian Ethics ■■ Compare© andJones contrast & these Bartlett theories. Learning,Hinduism. LLC Hinduism is an ancient© ethical Jones sys -& Bartlett Learning, LLC ■■ DiscussNOT whether FOR the theories SALE are ORethics DISTRIBUTION tem. It originated with writings calledNOT the VedasFOR SALE OR DISTRIBUTION theories. Defend your rationale. (ca. 2000 to 1000 BCE), which include magical, religious, and philosophical teachings, and existed long before the well-known ethical phil- Eastern Ethics osophy of the ancient Greeks. The main em- © JonesEthics &in AsianBartlett societies Learning, has similarities LLC to and phasis in Hindu© ethics Jones is cosmic & Bartlett unity. Because Learning, LLC NOTimportant FOR SALE differences OR DISTRIBUTIONfrom Western ethics. of reincarnation,NOT people FOR are stuck SALE in maya OR, DISTRIBUTIONan In both cultures, ethics often is intertwined illusory, everyday, impermanent experience. with spiritual or religious thinking, but ethics The quality of one’s past actions, karma, influ- in Eastern societies is usually indistinguish- ences one’s present existence and future incar- able from general Eastern philosophies. Both nations or rebirths. Therefore, people need to © Jones & BartlettEastern Learning, and Western LLC philosophies of ethics © improveJones the& Bartlettgoodness of Learning, their actions, LLC which NOT FOR SALE ORexamine DISTRIBUTION human nature and what is needed for NOTwill subsequentlyFOR SALE improve OR DISTRIBUTION their karma. Liber- people to move toward well-being. However, ation, moksha, means the soul of each person some of the differences in the two cultural sys- is no longer reincarnated but becomes one with tems are quite interesting and distinct. the desirable cosmic or universal self, atman, Whereas the goal of Western ethics is and the absolute reality of Brahman. generally for© people Jones to understand & Bartlett themselves Learning, LLC © Jones & Bartlett Learning, LLC personally, theNOT goal FOR of Eastern SALE ethics OR is DISTRIBUTIONoften Buddhism. The historical Buddha,NOT Siddhartha FOR SALE OR DISTRIBUTION to understand universal interconnections, Gautama (6th century BCE) was a Hindu prince. be liberated from the self, or understand that Because Siddhartha’s father wanted to prevent people really do not consist of a self at all (Ze- the fulfillment of a prophecy that Siddhartha uschner, 2001). Ethics viewed from Christian might become a spiritual teacher, he tried to © Jonesor other & Bartletttheological Learning,perspectives tendsLLC to be shield his son from© Jones the world & outside Bartlett his palace. Learning, LLC NOTbased FOR on SALE a belief OR in human DISTRIBUTION flaws that require However, SiddharthaNOT left FOR the confinement SALE OR of hisDISTRIBUTION an intermediary (God) to transcend these im- palace and saw in his fellow human beings the perfections. Eastern ethical systems are usually suffering associated with sickness, old age, and

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death. He decided to devote his life to under- Because of the central place of virtues in standing© Jones and ending & suffering.Bartlett Learning, LLCBuddhist philosophy, one© interpretationJones & Bartlett of Learning, LLC InNOT Buddhism, FOR there SALE is no OR creator DISTRIBUTION God. The Buddhist ethics is to identifyNOT Buddhism FOR SALEas an OR DISTRIBUTION Buddha’s core teachings, the teachings that all ethic of virtue. There are four virtues singled Buddhist sects profess, are called the Four No- out by Buddhists as being immeasurable be- ble Truths. The First Noble Truth is that un- cause, when these virtues are cultivated, it is satisfactoriness or suffering (dukkha) exists as believed they will grow in a way that can en- © Jones &a part Bartlett of all forms Learning, of existence. LLC This suffering compass ©and Jones transform & Bartlettthe whole world.Learning, The LLC NOT FORis SALEdifferent OR from DISTRIBUTION the common Western no- Four ImmeasurableNOT FOR Virtues SALE are OR compassion DISTRIBUTION tion of physical or mental misery; suffering (karuna), loving-kindness (metta), sympa- in a Buddhist sense, for example, arises when thetic joy (mudita), and equanimity (upekkha). people are ego centered and cling to their impermanent existence and impermanent Chinese Ethics © Jones & Bartlett Learning,things. Suffering LLC is emphasized in Buddhism© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONnot to suggest a negative outlook towardNOT life FORThe twoSALE most OR influential DISTRIBUTION Chinese ethical sys- but instead as a realistic assessment of the hu- tems were developed between 600 and 200 BCE man condition. The Second and Third Noble during a time of social chaos in China. The Truths suggest that the cause of suffering is two systems are Taoism and Confucianism. attachment (clinging or craving) to impermanent things© Jones and suffering & Bartlett can be Learning, transcended LLCTaoism. The beginning of Taoism© Jones is attributed & Bartlett Learning, LLC (enlightenment).NOT FOR The SALE Fourth OR Noble DISTRIBUTION Truth to Lao-Tzu (ca. 571 BCE), whoNOT wrote FOR the TaoistSALE OR DISTRIBUTION contains the path for transforming suffering guide to life, the Tao Te Ching. The word tao is into enlightenment or liberation. This path is translated to English as way or path, meaning called the Eightfold Path, and it is composed of the natural order or harmony of all things. Like eight right practices: Right View, Right Think- Buddhists, Taoists do not believe in a creator © Jones &ing, Bartlett Right Mindfulness, Learning, Right LLC Speech, Right God. Instead,© Jones Taoists & have Bartlett a very simpleLearning, per- LLC NOT FORAction, SALE Right OR Diligence, DISTRIBUTION Right Concentration, spective NOTtoward FOR reality—the SALE underlying OR DISTRIBUTION pur- and Right Livelihood. pose of humans and the underlying purpose of nature cannot be separated. Based on the cy- clic nature of life observed by ancient Chinese ETHICAL REFLECTION farmers, Taoist philosophy underscores the © Jones & Bartlett Learning, LLC © Jonesflux & and Bartlett balance ofLearning, nature through LLC yin (dark) and yang (light) elements. Living well or ethic- NOT FOR SALE OR DISTRIBUTIONThe Buddhist Avatamsaka Sutra contains a storyNOT FOR SALE OR DISTRIBUTION ally is living authentically, simply, and unself- about how all perceiving, thinking beings are connected, similar to a universal community. ishly in harmony and oneness with nature. The story is about the heavenly net of the god Indra. “In the heaven of Indra, there is said to Confucianism. K’ung Fu-tzu (551–479 BCE), be a© network Jones of pearls, & Bartlett so arranged Learning, that if you LLCwho was later called Confucius© Jones by Christians & Bartlett Learning, LLC lookNOT at one youFOR see allSALE the others OR reflected DISTRIBUTION in visiting China, originated NOTthe Confucian FOR SALE eth- OR DISTRIBUTION it. In the same way each object in the world is ical system. The teachings of Confucian ethics not merely itself but involves every other object are generally contained in the moral maxims and in fact is everything else. In every particle of and sayings attributed to K’ung Fu-tzu along dust there is present Buddhas without number” with the later writings of his followers. Confu- © Jones & (BartlettJapanese Buddhism Learning, by Sir Charles LLC Eliot © 2000, © Jones & Bartlett Learning, LLC Psychology Press [Taylor & Francis]). cian ethics is described through the concepts NOT FOR SALEHow ORis the DISTRIBUTIONstory about the net of Indra of li andNOT yi (Zeuschner, FOR SALE 2001). OR Li DISTRIBUTIONprovides related to ethics? guidance in regard to social order and how humans should relate to one another, including

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rules of etiquette, such as proper greetings and of Confucian ethics is jen, which is translated social rituals.© Yi Jones emphasizes & Bartlett the importance Learning, of to EnglishLLC as benevolence or human© goodness.Jones & Bartlett Learning, LLC one’s motivationsNOT towardFOR SALEachieving OR rightness DISTRIBUTION Overall, Confucianism is a communitarianNOT FOR SALE OR DISTRIBUTION rather than emphasizing consequences. Sin- ethical system in which social goals, the good cerity, teamwork, and balance are critically im- of society, and the importance of human rela- portant to ethical behavior. The primary virtue tionships are valued. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORKEY SALEPOINTS OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

■■ Ethics refers to the analysis of matters of right and wrong, whereas morals refer to actual beliefs and behaviors. However, the terms often are used interchangeably. ■■ Values refer to judgments about what one believes is good or makes something desirable. Values © Jones & Bartlett Learning,influence how LLC a person’s character develops and© people Jones think & and Bartlett subsequently Learning, behave. LLC NOT FOR SALE OR■■ DISTRIBUTIONNormative ethics is an attempt to decide or prescribeNOT values, FOR behaviors, SALE and OR ways DISTRIBUTION of being that are right or wrong, good or bad, admirable or dishonorable. When doing normative ethics, people ask questions such as “How ought humans behave?” “What should I do?” and “What sort of person should I be?” ■■ Ethical thinking, valuing, and reasoning generally fall along a continuum between ethical relativism and ethical© Jones objectivism. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ The studyNOT of values FOR and SALE ways of moralOR reasoningDISTRIBUTION throughout history can be useful for peopleNOT living FOR SALE OR DISTRIBUTION in the 21st century. Specific values and ways of moral reasoning tend to overlap and converge over time. ■■ Virtue ethics emphasizes the excellence of one’s character. ■■ Deontological ethics emphasizes one’s duty rather than the consequences of one’s actions. ■■ Utilitarian ethics emphasizes the consequences of one’s actions in regard to achieving the most © Jonesgood & Bartlett for the most Learning, people affected LLC by a rule or action. © Jones & Bartlett Learning, LLC NOT FOR■■ Eastern SALE philosophies OR DISTRIBUTION and systems of ethics often are inseparable. NOT FOR SALE OR DISTRIBUTION

© Jones & BartlettReferences Learning, LLC © Jones & Bartlett Learning, LLC American Hospital Association. (2003). The patient care Brannigan, M. C., & Boss, J. A. (2001). Healthcare ethics in NOT FOR SALE ORpartnership: DISTRIBUTION Understanding expectations, rights, and NOTa FORdiverse society. SALE Mountain OR View,DISTRIBUTION CA: Mayfield. responsibilities. Chicago, IL: Author. Brookfield, S. D. (2005). The power of critical theory: American Nurses Association. (2015). Code of ethics for Liberating adult learning and teaching. San Francisco, nurses with interpretive statements. Silver Spring, MD: CA: Jossey-Bass. Author. Buckle, S. (1993). Natural law. In P. Singer (Ed.), A companion Annas, J. (2011).© Intelligent Jones virtue & Bartlett[Kindle version]. Learning, New LLCto ethics (pp. 161–174). Malden, MA: Blackwell.© Jones & Bartlett Learning, LLC York, NY: Oxford University Press. Charon, R., & Montello, M. (2002). Introduction: The practice Aristotle. (2002).NOT Nichomachean FOR ethicsSALE (C. Rowe, OR Trans.).DISTRIBUTION of narrative ethics. In R. Charon & M. NOTMontello FOR(Eds.), SALE OR DISTRIBUTION Oxford, UK: Oxford University Press. Stories matter (pp. ix–xii). New York, NY: Routledge. Beauchamp, T. L., & Childress, J. F. (2013). Principles of Donahue, M. P. (1996). Nursing the finest art: An illustrated biomedical ethics (7th ed.). New York, NY: Oxford history (2nd ed.). St. Louis, MO: Mosby. University Press. Gert, B., Culver, C. M., & Clouser, K. D. (2006). Bioethics: Billington, R. (2003). Living philosophy: An introduction to A systematic approach (2nd ed.). New York, NY: © Jonesmoral & thought Bartlett (3rd ed.). Learning, London, UK: Routledge. LLC Oxford University© JonesPress. & Bartlett Learning, LLC NOTBohman, FOR J.SALE (2005). Critical OR theory.DISTRIBUTION Retrieved from http:// Gilligan, C. (1982).NOT In a different FOR voice: SALE Psychological OR theory DISTRIBUTION plato.stanford.edu/archives/spr2005/entries/critical and women’s development. Cambridge, MA: Harvard -theory/ University Press.

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Hope, T. (2004). Medical ethics: A very short introduction. Sellman, D. (1997). The virtues in the moral education of New© York,Jones NY: Oxford & Bartlett University Press. Learning, LLC nurses: Florence Nightingale ©revisited. Jones Nursing & Ethics, Bartlett Learning, LLC LeVasseur, J. (1998). Plato, Nightingale, and contemporary 4(1), 3–11. nursing.NOT Image: FOR Journal SALE of Nursing OR Scholarship, DISTRIBUTION 30(3), Tong, R. (1997). Feminist approachesNOT to bioethics: FOR Theoretical SALE OR DISTRIBUTION 281–285. reflections and practical applications. Boulder, CO: MacIntyre, A. (1984). After virtue: A study of moral theory Westview Press. (2nd ed.). Notre Dame, IN: University of Notre Dame Tschudin, V. (Ed.). (2003). Approaches to ethics: Nursing Press. beyond boundaries. Edinburgh, UK: Butterworth- © Jones &Murray, Bartlett T. H. (1997). Learning, What do we LLC mean by “narrative Heinemann.© Jones & Bartlett Learning, LLC ethics”? Medical Humanities Review, 11(2), 44–57. Zeuschner, R. B. (2001). Classical ethics East and West: NOT FORPence, SALE G. (2000). OR ADISTRIBUTION dictionary of common philosophical Ethics NOTfrom a comparativeFOR SALE perspective. OR Boston, DISTRIBUTION MA: terms. New York, NY: McGraw-Hill. McGraw-Hill. Ross, W. D. (2002). The right and the good. Oxford, UK: Oxford University Press. (Original work published 1930) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284171204_CH01.indd 25 04/10/18 11:53 AM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION