J Med Ethics: first published as 10.1136/jme.18.4.202 on 1 December 1992. Downloaded from Jrournal ofmedical ethics, 1992, 18, 202-205 Gilligan: a voice for nursing? Jean Harbison Glasgow South College, College ofNursing, Glasgow Author's abstract uses rules and principles to make a rational justification of choices. High values are placed on individual The current reform ofnursing education is resulting in autonomy, personal liberty and human rights. The major changes in the curricula ofcolleges ofnursing. For problems of morality are defined in terms of conflicts: thefirst time, ethical and moral issues are beingseen as an solutions are reached by ordering rights. This important theme underpinning the entire course. perspective has been termed one of justice (15), and it The moral theorist with whose work most nurse teachers is one which underlies the framework of rules and are acquainted is Kohlberg. In this paper, it is suggested principles which dominates thinking on biomedical that his work, and the conventions ofmorality which he ethics. Kohlberg, in his research on adolescents claims exemplifies, may not be the mostappropriatefrom which to to distinguish clear stages in moral development: address the moral issuesfacing the nurse. preconventional: where responses to moral dilemmas The author suggests that the work ofCarol Gilligan of are absolute and egocentric; conventional: where copyright. Harvard university is ofgreat significance, not onlyfor responses are related to societal, moral and legal codes, nurses involved in the teachingofethics, butforall nurses. and post-conventional: where universal moral Gilligan's emphasis on caring and relationships accords principles inform the response, regardless of societal with the common experience ofthe nurse, and echoes the codes. Operational thought, as defined by Piaget, is a current revival ofinterest within nursing in examining, prerequisite (though not a guarantee) of the higher and valuing, the phenomenon ofcaring. stages of moral response. Kohlberg's research was carried out on adolescent boys, and appeared to be There is growing interest among nurse educators in http://jme.bmj.com/ developing the critical-thinking skills of students applicable across several cultures. (1,2,3,4,5). This may in part be due to the influence of However, the applicability of this theory to adults Schon's views on the role of critical reflection in the has been queried by Murphy and Gilligan (16). In development ofa professional practitioner (6,7). There addition, Riegel's theory of dialectical operational is increasing interest also in preparing nurses to thought claims that adults are capable of further consider the ethical and moral implications of the cognitive development, and therefore by implication, situations with which they are daily faced (8,9,10). moral reasoning development (17). The applicability Critical scrutiny of practice, according to Schon, of Kohlberg's theory to women has also been queried on September 30, 2021 by guest. Protected demands a sound knowledge-base from which to by Gilligan (15). It has been suggested that the work of reflect. McInerny challenges health-care professionals Harvard educator Carol Gilligan is deserving of to be as familiar with as many ethical theories as consideration by nurses (18). Study of Gilligan's possible in order to be able critically to scrutinise moral writings indicates that her ideas on moral development thinking (11). The theory of moral development are more relevant to the moral experience of the nurse usually considered by nurse teachers (12) is that of than those of Kohlberg. Kohlberg (13) whose work is paralleled by Piaget (14) in the field of cognitive development. Gilligan's work on moral development Kohlberg's theory of moral development (15,16,19,20,21) Our moral judgements reflect our understanding of Kohlberg's work is based on Kant's model of moral ourselves and of society. They are derived from our autonomy and reason. The moral agent is characterised experience of human relationships. Within the parent/ as one who objectively analyses moral dilemmas and child relationship, according to Gilligan, we experience both attachment and inequality. We Key words therefore develop from this experience ideas about care Nursing; nursing education; nursing ethics; moral and justice. It is Gilligan's contention that since the development; moral decision-making; ethical decision- experience of girls is different from boys, it is logical making. that they will develop different understandings of self J Med Ethics: first published as 10.1136/jme.18.4.202 on 1 December 1992. Downloaded from Jfean Harbison 203 and society and, therefore, different ways of viewing necessarily uncaring, and caring is not necessarily moral issues. unjust. The two views of morality are therefore Gilligan therefore challenges Kohlberg's moral complementary rather than opposed. Although it is development theory on the grounds that the traditional impossible to view a moral problem from both assumptions of moral philosophy fail to reflect perspectives simultaneously, it is possible to attempt a women's experience. Gilligan suggests that, where the shift in perspective. This may mean a re-definition of moral reasoning ofgirls would be defined by Kohlberg the problem. as being deficient in moral development, this is due to As Blum (22) points out, a dominant concept in the different emphasis placed by them on maintaining western morality has been that of what he terms and strengthening relationships. The perspective 'impartialism', or what Gilligan would call women have on morality, which Kohlberg classifies as 'detachment'. The cult of the individual in our society deviance, is understood by Gilligan to reflect women's has traditionally placed a value on detachment. (As social and moral understanding and to be equally valid, Gilligan points out, Sigmund Freud claimed to detect rather than deviant. a failure of moral development in women as Central to Gilligan's thinking is the meaning of characterised by a reluctance to develop an attitude of responsibility. Conventionally it carries the meaning of detachment.) The self, though placed in the context of commitment to obligations. Gilligan would extend that relationships, is defined in terms of separation. The definition to include also responsiveness within capacity for engagement with others is observed during relationships. Common understanding is that development, but is not well represented in accounts of responsibility means making a commitment and human development. Gilligan suggests that this may sticking to it. In Gilligan's extended understanding, it be because it is at odds with the current concepts of means also being aware of others and their feelings; self. In Gilligan's vision, dependence is assumed to be taking charge of oneself by looking at others and their part of the human condition; being dependent is not needs, and taking the initiative. This construction of regarded as being helpless and powerless, but simply responsibility implies that the moral agent acts being convinced that people have an effect upon each responsively in relationships. A moral agent therefore other, and recognising that interdependence is characterised as one who responds to need and empowers both. The reference for moral judgementcopyright. demonstrates a consideration ofcare and responsibility now becomes, not oneself, but the relationship in relationships. In this understanding, morality is between the self and others. seen as grounded in a perspective of caring. It is Therefore, although from the justice perspective suggested that it is from this caring perspective that detachment is an advantage, allowing objective females view moral and ethical decision-making. decision without passion; from the caring perspective, There are therefore two (at least) possible detachment in fact becomes a moral problem. The first perspectives from which to make moral judgements: perspective seeks to reconcile two separate positions; http://jme.bmj.com/ the conventional perspective, that which Gilligan the second seeks to understand the relationship terms 'justice', and women's perspective, termed that between two connected positions. From the first of 'care'. Gilligan claims that the two moral 'voices' can perspective, the ideal to be attained is perfection, be clearly distinguished in the way people frame and against which the self is measured; from the second, resolve moral problems and evaluate choices. The the ideal is care, against which the worth of one's conventional voice speaks of equality, reciprocity, actions is measured. justice and rights. These terms imply individual separation, hierarchical and contractual relationships, The relevance of Gilligan's work to nursing on September 30, 2021 by guest. Protected and the alternatives of constraint or co-operation. The Gilligan's emphasis on caring and relationships accords female voice speaks of connection, not hurting, care with nurses' common experience, and is echoed in the and response. These terms imply interdependent renewed interest in nursing literature in the individuals, and networks of relationships created and phenomenon of caring since the mid 1970s (23,24,25, maintained by attention and response. The two voices 26). Patricia Benner, in her important descriptive are seen to represent predominant, but not exclusive, study of nursing, as practised by experienced nurses, patterns of thinking in any individual. identifies the central place which caring,