Ethics and morality

Ethics (which may be used interchangeably with the term ‘moral’) is a general term used for referring to various ways of understanding and examining the ‘moral life’ (Beauchamp and Childress, 2009). More specifically, ethics involves thinking critically about and engaging in a systematic examination of what constitutes right and wrong/good and bad behaviour, and the bases upon which we might justify our judgments that an action or decision is ‘morally right or wrong’, all things considered. For example, a nurse may make the moral judgment that abortion is wrong and conscientiously object to assisting with an abortion procedure. Whether conscientious objection ought to be permitted, however, requires a critical examination of the bases on which the nurse has made that judgment, and the provision of sound (moral) justifications (reasons) for the action taken. Ethics, then, is concerned not just with giving values to certain things (e.g. abortion is right/wrong, good/bad), but also with justifying the bases on which judgments about these things might be made (Johnstone, 2009a; Kerridge and others, 2009; LaFollette, 2007).

It is important to clarify the use of the term ‘morality’ in discussions on ethics. In some nursing texts, the terms ‘ethics’ and ‘morality’ are treated as though they refer to different things. This use, however, is not correct. There is, in fact, no philosophically significant difference between the terms ‘ethics’ and ‘morality’, and hence they may be used interchangeably. The only distinction that may be drawn with validity between these two terms is that the word ‘ethics’ comes from the Greek ethikos (originally meaning custom or habit), and ‘morality’ from the Latin moralitas (also originally meaning custom or habit) (Johnstone, 2009a). Of course, today these terms refer to something much more sophisticated than merely custom or habit, as this chapter will show.

Bioethics

The term bioethics (from the Greek bios meaning life, and ethikos, ithiki meaning ethics)—literally, ethics in the realm of life—is a relatively new term that first found its way into public use in the early 1970s in the United States (Reich, 1994). Although the term was originally defined to include environmental concerns, as it is used today its main focus is on (Reich, 1995):

Although originating in the United States, bioethics has developed as a discipline in its own right in countries around the world; it has also developed as a major international movement of popular interest to professionals and laypersons alike. Today, issues most commonly the subject of bioethics debate in professional journals, as well as in the mass circulation media, include:

Nursing ethics

Contemporary nursing ethics has been profoundly influenced by the modern bioethics movement and, in several respects, could even be described as a subcategory of bioethics; that is, nursing bioethics. Despite this modern influence, it is important to acknowledge that the nursing profession has its own rich and distinctive history of identifying and responding effectively to ethical issues in nursing and healthcare. In addition to having its own distinctive history of professional ethics, nursing can be said to have developed its own distinctive (nursing) ethics. This development not only has been necessary, but also was inevitable. It has been necessary because ‘a profession without its own distinctive moral convictions has nothing to profess’ and will be left vulnerable to the corrupting influences of whatever forces are more powerful (be they social, political, legal or other in nature) (Churchill, 1989). Furthermore, as Churchill (1989) has asserted in his classic article on the subject, ‘Professionals without an ethic are merely technicians who know how to perform work, but who have no capacity to say why their work has any larger meaning.’ Without meaning, there is little or no motivation to perform well.

What, then, is nursing ethics? Nursing ethics can be defined broadly as the examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice, which in turn rest on the agreed core concepts of nursing, namely person, culture, care, health, healing, environment and nursing itself (or, more to the point, its end good), all of which have been comprehensively articulated in the nursing literature. In this regard, then, nursing ethics is not synonymous with, and indeed is greater than, an ethic of care, although an ethic of care has an important place in the general scheme of things encompassing nursing and nursing ethics.

Unlike other approaches to professional and healthcare ethics, nursing ethics recognises the ‘distinctive voices’ that are nurses, and emphasises the importance of collecting and recording nursing ‘stories from the field’. Like other approaches to ethics, however, nursing ethics recognises the importance of providing practical guidance on how to decide and act morally. Drawing on a variety of ethical considerations, nursing ethics, at its most basic, could thus also be described as a nursing practice discipline which aims to provide guidance to nurses on how to decide and act morally in the contexts in which they work.

Moral principles

General standards of conduct that make up an ethical system are known as moral principles. To say that a principle is moral is merely to assert that it is a behaviour guide that entails particular imperatives or obligations; that is, to do or to refrain from something that may have a morally significant outcome. It is generally accepted that moral principles function by specifying that some type of action or conduct is prohibited, required or permitted in certain circumstances (Beauchamp and Childress, 2009; Johnstone, 2009a). By this view, an action or behaviour is generally considered morally right or good if it accords with a given moral principle, and morally bad or wrong when it does not.

Moral principles commonly referred to in healthcare ethics include those of autonomy, non-maleficence, beneficence and justice (see section on moral theories, below). To illustrate how moral principles work, consider the principle of autonomy. The principle of autonomy demands respect for individuals as self-determining choosers and is widely accepted as a general standard of moral conduct. Given this principle, conduct which respects an individual’s self-determining choices (e.g. a client’s competent decision not to accept a recommended medical treatment) could be appraised as having accorded with the principle of autonomy and therefore as being morally ‘right’ and justified. Conversely, conduct which is disrespectful of an individual’s choices (e.g. a competent client’s decision to refuse medical treatment is rejected and overridden by a professional caregiver) could be appraised as having violated the principle of autonomy and therefore as being morally ‘wrong’. Moral principles thus not only guide conduct, but they can also be appealed to for justifying the conduct in question.

Moral rules

Like moral principles, moral rules also have a place in making up a system or scheme for guiding moral action. And like moral principles, moral rules also function by specifying that some type of conduct is prohibited, required or permitted (Beauchamp and Childress, 2009; Johnstone, 2009a). What distinguishes a moral rule from a moral principle, however, is its nature and force. Moral principles, for example, tend to be general in nature (e.g. do no harm; promote good). Moral rules, in contrast, are both derivative of, and justified by, parent principles and are very specific in their focus (e.g. do not kill others; do not tell a lie). It can be seen, then, that moral rules have a different force, sanctioning power, condition of existence, scope of application and level of concreteness from moral principles. In application, they are generally regarded as having less force than principles.

Rights

Common to discussions on nursing ethics is the notion of rights—including moral rights, human rights and clients’ rights. An understanding of these key terms is, therefore, warranted.

Moral duties

A moral duty (to be distinguished from a legal duty, a civic duty and so on) is an action which a person is bound, for moral reasons, to perform. Language used in identifying duties typically involves expressions such as ‘I have a duty …’, ‘You have a duty …’, and so on. In a rights view of ethics, someone claiming a valid right supplies a moral reason for why another must act morally towards them. Indeed, moral duties are sometimes described as being correlative; that is, in relation to another’s rights claims. To put this in another way, if one person claims a right, this may entail another having a correlative duty to respect and respond to that right. For example, if a client claims the right to make an informed decision regarding nursing care, then an attending nurse could be said to have a correlative duty to respect and uphold that right. Moral reasons can also be supplied by an appeal to ethical principles. For example, adoption of the principle of autonomy would impose on decision makers a duty to uphold its prescriptions; namely, to respect people as self-determining choosers.

A critical task for decision makers is deciding just what their duties are in given situations. Making the correct decision depends on determining what counts as an overriding moral reason for doing something (bearing in mind that moral reasons are generally regarded as being stronger or more pressing than other kinds of reasons, such as personal preferences, civic duty and group membership). For example, in the case of a rights claim being made, whether or not another has a corresponding duty will depend on whether the right being claimed is genuine, whether the entity has moral rights at all and whether an agent does in fact have a duty correlative to the rights claim being made.

Sometimes people confuse rights with duties, and vice versa. A useful way to guide an understanding of the distinction between rights and duties is to consider that when people claim a right they are making a claim with respect to their own interests; in contrast, when people claim a duty they are making a claim with respect to the interests of another or others.

Moral accountability and responsibility

In identifying and responding effectively to moral problems in the workplace and, indeed, when practising in a professional capacity generally, nurses are morally accountable and responsible for their actions (Johnstone, 2009a). Thus, when a nurse breaches the agreed ethical standards of the nursing profession, there is an expectation that they will be made to account for and, ultimately, be held responsible for their conduct. Moral accountability and responsibility, however, do not reside only in individual nurses. The nursing profession as a whole, and those charged with the responsibility of regulating it, are also morally accountable and responsible for their actions. This is an important point, since it has a significant bearing on the kinds of strategies that might otherwise be used to respond effectively to situations in which the agreed ethical standards of the profession are at risk of being or have already been breached.

Understanding the nature and moral implications of professional accountability and responsibility in nursing requires a commensurate understanding of moral theories of accountability and responsibility. For instance, in the philosophical literature, accountability has classically been taken to mean:

In turn, the notion of responsibility (of which accountability is a form) has been taken broadly to include not only one’s ‘intentional conduct’ (i.e. a person’s deliberate acts and omissions), but also:

Drawing on both of the above accounts, moral theories of accountability hold that:

Theories of moral accountability tend to emphasise accountability to oneself or to a superior entity. Either way, claims of moral accountability tend to assume that:

As well, some form of external mechanism (e.g. an ethics complaints committee) is also essential to human interaction (Spencer and others, 2000).

It can be seen, then, that the issues of moral accountability and responsibility have important implications for nurses. For instance, an ongoing problem facing the nursing profession is that although nurses have enormous responsibilities as healthcare providers, they often lack the lawful authority they need in order to be able to fulfil these responsibilities in a safe and effective way (Johnstone, 1994, 2009a).

Guides to ethical professional conduct

As has previously been considered, when making moral judgments and decisions in nursing care domains, nurses are often faced with such perplexing questions as ‘What should I do and what is the right thing to do in such-and-such situation?’, ‘Are my judgments and decisions morally correct, all things considered?’, ‘How should I decide?’ and ‘Have I done (am I doing) the right thing?’ These and similar questions become even more pressing when considered against the backdrop of stringent moral accountabilities and responsibilities otherwise expected of registered nurses.

Possible answers to these and related questions can be sought by appealing to moral theories and/or nursing codes of conduct; noting, however, that neither of these is without some difficulties with respect to their moral authority and capacity to guide and justify particular actions in specific contexts. As Beauchamp and Childress (2009) explain, ‘Many practical questions would remain unanswered even if a fully satisfactory general ethical theory were available.’

Deontological ethics

According to deontological ethics, duty is the basis of all moral action. Taken at its most basic, deontology asserts that some acts are obligatory (duty bound) regardless of their consequences. For example, a deontologist might assert that one has a duty to always tell the truth. By this view, the deontologist is duty bound to always tell the truth even when doing so might have horrible consequences. An important question to ask here is: How do we know what our duty is?

One possible answer to this question can be found in classical deontological theory that derives from religious ethics and what is otherwise known as ‘divine command theory’. According to this view, it is God’s command that determines our moral duties. If, for example, God commands ‘Thou shalt not kill’, ‘Thou shalt not steal’ and the like, then conduct that accords with (obeys) these commands is morally praiseworthy (right and justified). Conduct that contradicts God’s commands, in contrast, warrants condemnation (as wrong and unjustified). This is because and only because it is God’s command (Morriston, 2009; Wainwright, 2005).

There are many examples of deontological ethics influencing decision making in healthcare domains. For example, Jehovah’s Witnesses refuse life-saving blood transfusions on the grounds that to accept such treatment would be tantamount to violating God’s command that prohibits taking blood. Another example can be found in a deontological adherence by some doctors and surgeons to the preservation of ‘medically hopeless’ human life whatever the costs (read ‘consequences’), resulting in the administration of ‘futile’ medical treatment to clients sometimes even against their will (Schneiderman and Jecker, 2011).

Another answer can be found in what is otherwise known as ethical rationalism. This view dates back to the work of the 18th-century German philosopher Immanuel Kant, who held that the supreme principle of morality was reason, whose ultimate end is goodwill. According to a 1972 translation, Kant stated that reason is free (autonomous) to formulate moral law and to determine just what is to count as being an overriding moral duty. Kant held duty to be that which is done for its own sake, and ‘not for the results it attains or seeks to attain’ (Kant, 1972). Kant further believed that moral considerations (duties) were always overriding in nature—in other words, should take precedence over other considerations.

In terms of determining what one’s actual duty is, Kant suggested that this can be done by appealing to some formal (reasoned) principle or maxim. In choosing such a maxim, however, Kant warned that we must take care not to choose something that would privilege our interests over the interests of others. Kant’s solution to this problem was to establish a universally valid law called the ‘categorical imperative’. This law states: ‘Act only on that maxim through which you can at the same time will that it should become universal law’ (Kant, 1972). In other words, we should act only on maxims that we are prepared to accept as holding for everybody (including ourselves) throughout space and time. A variation of Kant’s law can be found in what is popularly known as the Golden Rule: ‘Do unto others as you would have them do unto you.’

Teleological ethics

According to teleological theory (also known as consequentialism), actions can be judged right and/or good only on the basis of the consequences they produce. In this respect, teleology denies everything that deontology asserts.

The most popularly known teleological theory of ethics is utilitarianism, which has as its central concern the general welfare of people as a whole, rather than of individuals. In short, utilitarianism views the world not in terms of certain individual rights which people may or may not claim, but in terms of the collective and overall welfare and interests of people generally (a consequentially ‘good outcome’). The perspective of utilitarianism is persuasive in that it promotes a universal point of view; namely, that one person’s interests cannot count as being superior to the interests of another just because they are personal interests (Rosen, 2003). To put this in another way, I cannot claim that my interests are more deserving than your interests are, just because they are my interests.

Classical utilitarianism, first advanced by the English philosopher Jeremy Bentham (1748–1832) and later modified by the work of the British philosopher John Stuart Mill (1806–73), holds roughly that moral agents have a duty to ‘maximise the greatest happiness/good for the greatest number’ (Bentham, 1962; Mill, 1962). This view has resulted in classical utilitarianism being dubbed the ‘greatest happiness principle’. Because of difficulties associated with calculating both individual and collective happiness and unhappiness, and the problem of individual interests being sacrificed for the collective whole, classical utilitarianism theory has been largely abandoned in favour of recent utilitarian theory. Of particular note is ‘preference utilitarianism’, which views the maximisation of individual preferences as being of intrinsic value rather than the maximisation of happiness per se. This is because, as Beauchamp and Childress (1989) have classically explained, ‘what is intrinsically valuable is what individuals prefer to obtain, and utility is thus translated into the satisfaction of those needs and desires that individuals choose to satisfy.’

Preference utilitarianism is also considered more plausible because it is relatively easy to calculate what people’s preferences are—all we have to do is to ask people what it is they prefer. And where their preferences are at odds with ethical conduct, we have no obligation to respect them. This position, however, rests on assumptions about the ‘use’ of utility and its supposed intrinsic value, which some contend it does not have (Millgram, 2000).

Ethical principlism

One of the most popular ethical theories used today when considering ethical issues in nursing and healthcare is the theory of ethical principlism. Ethical principlism is the view that ethical decision making and problem solving are best undertaken by appealing to sound moral principles (Beauchamp and Childress, 2009). The principles most commonly used are those of autonomy, non-maleficence, beneficence and justice.

Moral rights theory

Another popular and commonly used moral theory is that of moral rights theory, a form of deontological ethics. Moral rights have been particularly influential in the development of discourses on clients’ rights and the development of various codes and charters outlining clients’ rights in healthcare (Weller, 2006). As discussed earlier, a moral right is a special interest that a person may have and which ought to be protected and upheld for moral reasons.

There is no simple thesis of moral rights (Campbell, 2006; Dyck, 2005). Indeed, there are a number of bases on which an entity could validly claim moral rights, including natural law, common humanity, rationality and interests.

Virtue ethics

In recent times there has been a resurgence of virtue theory in ethics and a re-examination of the importance of ‘characterological excellence’ in determining ethical conduct (Oakley, 2006; Van Hooft, 2006). This is made manifest by the expression of such moral virtues as care, compassion, kindness, empathy, sympathy, altruism, generosity, respectfulness, trustworthiness, personal integrity, wisdom, courage and fairness. Virtue theorists claim that without the characterological excellence of virtue, ‘a person could, robot-like, obey every moral rule and lead the perfectly moral life’ but in doing so would be acting more like ‘a perfectly programmed computer’ than a morally responsible human being (Pence, 1991). There is a sense in which being moral involves much more than merely following rules; the missing link, claim virtue theorists, is character. On this point, Pence (1991) writes:

Virtue ethics is particularly relevant to nursing and to nursing ethics since virtuous conduct is intricately linked to therapeutic healing behaviours and the promotion of human health and wellbeing.

The nursing profession’s well-articulated ethic of care (regarded by many influential nurse theorists as the moral foundation, essence, ideal and imperative of nursing) is consistent with a virtue theory of ethics (see the classic works of the following nurse theorists: Benner and Wrubel, 1989; Gaut, 1991; Gaut and Leininger, 1991; Leininger, 1988, 1990; Roach, 1987; Watson, 1985a, 1985b). Significantly, an ethic of care is enjoying a renaissance in the nursing ethics literature—particularly in regard to the issue of caring for vulnerable and marginalised groups of people at risk of being treated as ‘different’ and as ‘others’ by healthcare providers (Myhrvold, 2006; Nussbaum, 2006).

Cross-cultural ethics

As highlighted by the ‘Mr G’ case discussed in the opening paragraphs to this chapter, another perspective on ethics and bioethics that warrants consideration by nurses is cross-cultural ethics. The basic assumptions of cross-cultural ethics reflect the views that:

In any culturally diverse society it is imperative that a culturally informed, knowledgeable and sensitive approach to healthcare is taken (Fry and Johnstone, 2008; Johnstone, 2011a; Johnstone and Kanitsaki, 2008). One reason for this is that a failure to adopt such an approach can result in otherwise serious moral harm being caused to people. Cross-cultural ethics, therefore, goes far beyond merely considering and critiquing the nature and content of mainstream ethical theories; it also involves a systematic examination of the moral implications of cultural and linguistic diversity in healthcare domains, for example the extent to which clients of non-English-speaking and diverse cultural backgrounds suffer unnecessarily on account of the cultural and language differences between them and their professional carers (see, for example, Divi and others, 2007; Johnstone and Kanitsaki, 2006, 2009a).

Nurses and other healthcare workers have a stringent moral responsibility to avoid and/or prevent the otherwise avoidable moral harms that can result from a failure to take into account the language and cultural needs of their clientele (Johnstone and Kanitsaki, 2006, 2008, 2009a). The harmful aftermath of racism in healthcare is a particular example of this. Racism in nursing and healthcare is a problem that has not been formally recognised as an important ethical professional issue (Johnstone and Kanitsaki, 2009b, 2010). A cross-cultural approach to ethics would not only help identify the existence of racism in nursing and healthcare contexts, but also guide an effective response for dealing with it and, if not successful in eradicating it, at least minimise its harmful consequences to client health.

Nursing point of view

When moral problems arise in healthcare contexts, the nurse’s observations and considered judgments (the ‘nursing point of view’) can play a vital role in the correct identification and mitigation of the problems at hand. Since nurses may be involved in very intimate physical acts with clients, such as bathing, feeding and special procedures, information that is not generally solicited by other attending healthcare workers, including doctors and social workers, is often revealed to nurses by clients and their families. Details about family life at home, information about coping styles or personal preferences and details about fears and insecurities may come out during nursing interventions. Such information can be vital to ensuring sound moral decision making concerning client care.

On the other hand, it is important for nurses to remember that care of any one client has become multidisciplinary and fragmented. The nursing point of view is part of a larger picture that is best built by all members of the healthcare team, including the client and family. Managers and administrators from different professional backgrounds may also contribute to ‘moral conversations’, as they are able to bring knowledge of systems, allocation of resources, financial possibilities or constraints to the decision-making process.

Wherever moral problems arise, the nursing point of view is valuable and often essential. It is both an obligation and a privilege for the professional nurse to accumulate information on the issues, examine personally held moral values and beliefs, and share knowledge with clients and with colleagues in an effort to overcome the difficult issues that often underlie and/or constitute moral problems in healthcare.

Distinguishing moral problems from other kinds of problems

Being able to identify and respond effectively to moral problems in professional practice requires an understanding of what a moral problem is and how it might be distinguished from other kinds of problems, for example a legal problem or a clinical problem.

It is generally accepted that a moral problem has as its central concerns:

Nurses are fundamentally involved with promoting and protecting people’s genuine wellbeing and welfare and, in achieving these ends, responding justly to the genuine needs and interests of different people. And so long as nurses work and interact with people in a professional capacity, they will continue to be involved in the promotion and achievement of these moral ends.

Moral problems (also called ethical issues) fall roughly into three categories:

Identifying and responding effectively to moral problems in nursing

All nurses are expected to be able to identify correctly and respond effectively to moral problems in the workplace. The kinds of problems that may be encountered are summarised below.

Processes of moral decision making

Moral problems, like other kinds of problems, can be approached using a systematic decision-making process. Like the nursing process, identifying and resolving moral problems in healthcare contexts involves at least five steps:

This model of moral decision making (see Figure 9-1) is by no means the only model that might be used to approach moral problems. Nevertheless, it is a very useful model and one that is relatively easy to use. It does, however, presuppose that decision makers have at least a working knowledge and understanding of ethics and the ability to think critically when applying ethics to and in professional practice. It would be useful at this point to briefly demonstrate how the model might be used (see Box 9-2, then read the clinical example overleaf before studying steps 1 to 5 of the discussion; consider also applying this process to the cases of Mr G and Ms Winnow, presented earlier in this chapter).

FIGURE 9-1 Moral decision making.

From Johnstone M-J 2009 Bioethics: a nursing perspective, ed 5. Sydney, Churchill Livingstone.

On your ward, a 35-year-old woman has been hospitalised in the final stages of a struggle with brain cancer. She is a single mother, with two young children at home. Despite treatment, the tumour continues to grow and the medical team has agreed that further treatment would be futile. You have cared for this client during past admissions, and during one especially open discussion, she expressed wishes to explore ‘do not resuscitate’ (DNR) directives. During the current admission, her medical consultant is out of town. The attending on-call doctor does not know the client personally, but he has spent some time with her. He has reviewed the clinical data and agrees that the client is entering advanced stages of her disease. In his opinion, however, the client is not ready to discuss end-of-life issues. In fact, he states that on being offered the option to discuss DNR, the client declined. You have asked him to convene a family conference to discuss DNR directives but he refuses to do so.

Clinical example discussion

Informed consent

The main aims of informed consent processes are to promote and protect the client’s right to self-determination, and to remind healthcare practitioners of their duty to provide clients with the information necessary to make intelligent choices about whether to accept recommended care and treatment (Faden and Beauchamp, 1986; Manson and O’Neill, 2007). The main way of meeting these goals has been to share knowledge about clinical findings and management plans as they are implemented. In certain well-defined situations, the client must provide written evidence of consent, such as consent to a surgical procedure or consent to participate in an experimental regimen.

The practice of informed consent has gained increasing acceptance and respect in Australia and New Zealand. Healthcare providers now go to great lengths to share information that promotes informed decision making. Institutional policies and civil law protect the client’s right to informed consent. Its practice represents a clear effort to respect the autonomy of clients, and in this way also represents a fundamental shift from the medical paternalism (‘doctor knows best’) that was once characteristic of healthcare practice.

A commitment to the concept of informed consent does not ensure a lack of controversy. The concept depends on a certain level of competence on the part of the provider to communicate well, and also depends on a level of competence on the part of the client to understand. It is not always easy to secure these competencies. Furthermore, studies on communication skills demonstrate that healthcare providers are more likely to share information with clients who have similar cultural backgrounds to the provider. Providers may be more likely to give directives or advice than truly to share knowledge with clients whom they perceive to be less educated or less intelligent and, in the case of clients who do not speak English or do not speak it proficiently, may even fail to communicate relevant information at all (Johnstone and Kanitsaki, 2006, 2009b).

For consent to be properly informed it must satisfy the following criteria:

Confidentiality

It is generally accepted that nurses, like other members of the healthcare team, have a stringent moral duty to keep secret any private information gained in the professional–client relationship. Nursing codes of ethics make explicit the nurse’s duty in this regard, and make it clear that nurses must exercise critical judgment if and when disclosing otherwise confidential information to a third party. The main aim of the rule of confidentiality is to protect clients against the morally harmful consequences that can occur when unconsented disclosures are made. An unconsented disclosure of, for example, a client’s newly diagnosed HIV-positive status could result in the client being rejected by family and friends and hence left without social support at a time when it is most needed. It might also result in the client losing his/her job, which although illegal still happens, compounding their loss of social support.

Confidentiality is not, however, an absolute principle. What this means is that although, as a general rule, we ought to keep information gained in the professional–client relationship secret, there may be times when disclosing such information is morally warranted. Indeed, it is generally recognised and accepted that sometimes there may be overriding moral reasons that disclosures should be made, for example where such disclosures could otherwise help prevent harm to innocent others. If a client disclosed that, for example, he intended to act out a revenge fantasy and kill someone he disliked, then the duty to keep this information confidential could be overridden by a stronger duty to warn the intended victim. In cases involving known or suspected cases of child abuse or elder abuse, disclosures might not only be morally warranted but legally mandated as well.

Quality of life

It is difficult to imagine a concept with a more personal, or more elusive, definition than quality of life. For each individual, quality of life is something that is intensely personal and particular. Yet society uses quality-of-life measures to help determine the benefits of medical intervention and, as a result, discussions about quality of life abound (Jecker and others, 2011; Kerridge and others, 2009). Some social scientists have proposed formulas or other objective measuring devices that can be applied to individual and group situations, and to whole populations (Rapley, 2003). These formulas might take into account the age of the client, ability to live independently and ability to contribute to society in a gainful way. Such a formula might help a committee determine, for example, the relative merits of giving an organ to one recipient over another. Or, a quality-of-life measure could help a client and family decide on the merits of a certain risky intervention, such as organ transplant or experimental drug management. The question of quality of life is paramount to discussions about futile care, euthanasia/medically assisted suicide, and DNR directives.

Given the diverse ways in which the notion of quality of life can be defined, it is important that nurses are clear about what they mean by this concept and that they ensure they do not inadvertently impose their views about what quality of life is on the client (Johnstone, 2009a).

Do not resuscitate (DNR) directives

At some stage during their practice, nurses will encounter clients who have been made the subject of a ‘do not resuscitate’ or DNR directive. A DNR directive (also sometimes written as a ‘do not attempt resuscitation’ (DNAR) or ‘not for resuscitation’ (NFR) directive) is made by an attending medical officer, and typically prescribes that in the event of a cardiac or respiratory arrest, no emergency resuscitation or life-supporting measures will be initiated. In other words, were the client to suffer a cardiac or respiratory arrest, CPR would not be performed. The issue of DNR has long been a controversial bioethical issue for nurses, as discussed elsewhere (Johnstone, 2009a). One reason for this has been that, at least in the past, it was not uncommon for DNR directives to be given without the client’s knowledge or consent. This was often justified on the questionable grounds that such knowledge would only cause the client unnecessary distress. Other problems related to:

Today, the issue of DNR is discussed much more openly with clients and their chosen carers as well as with members of the healthcare team. Nevertheless, the issue remains problematic and continues to invite debate in both the bioethics and the nursing ethics literature. Even though there have been notable improvements in the development and operationalisation of DNR policies and practices in local healthcare institutions, research has shown that wide variations continue to exist (Sidhu and others, 2007).

Euthanasia/medically assisted suicide

Euthanasia/medically assisted suicide involves the deliberate administration of a lethal substance to end a patient’s life, usually in a clinical context (Johnstone, 2009a). Some people request euthanasia in instances where they have come to view their life or suffering as ‘unbearable’. More recently, supporters of euthanasia have advocated advance euthanasia directives (also called ‘preemptive euthanasia’) whereby requests for euthanasia are made in advance of an anticipated state of suffering (mental or physical) being experienced (Hertogh, 2009). Nurses, like others in the community, hold diverse values, opinions and beliefs about the moral permissibility of euthanasia/medically assisted suicide and whether it should be legalised. Of particular concern to nurses in Australia and New Zealand (where euthanasia is illegal) is the confronting question of whether the nursing profession should formally and publicly support calls for the legalisation of euthanasia/medically assisted suicide and whether nursing organisations should adopt a formal policy position to this effect (Johnstone, 2010a). Also confronting is the question of whether nurses should themselves assist with performing euthanasia in the event of it being made legal. Nurses and professional nursing organisations have an obvious stake in the outcome of the euthanasia/medically assisted suicide debate (Johnstone, 2010a). Accordingly, nurses have a moral and professional responsibility to ensure that they are kept well informed about the issues in question and keep abreast of developments discussed critically in the legal and bioethics literature. This includes questioning and calling into question public opinion, which indicates nothing more than a certain percentage of the population holding a particular opinion on the matter. Whether public opinion (which currently favours the legalisation of euthanasia) has the authority to prescribe a society’s moral values is another matter entirely (Johnstone, 2009a).

Access and equity in healthcare

Access and equity in healthcare are poised to become the most pressing ethical issues in the 21st century. This is because over the next 40 years, population ageing, the increasing burden of chronic disease, the possible health consequences of climate change and the depletion of the world’s non-renewable resources (e.g. petroleum) will all place unprecedented and overwhelming demands on the healthcare system and the individuals comprising it. In the case of population ageing, people over the age of 65 years are expected to become frequent users of the public health system and that ‘real health spending’ during the period 2010 to 2050 will increase exponentially for this population group (Johnstone, 2010b; Johnstone and Kanitsaki, 2009c). Critics contend that the costs associated with an ageing population and associated burden of chronic disease will be so high that the level of healthcare currently being provided will not be sustainable. The future will therefore be one in which ‘tough moral choices’ will have to be made.

Adding to the problem of future access to and equity in healthcare is the potential negative impact of climate change. Experts predict that climate change will see a significant increase in illness and deaths from frequent and severe heat-waves, vector-borne diseases, and other extreme weather events (McMichael and others, 2006). Peak petroleum (the point at which the world’s oil reserves begin to decline, which some say may already have been reached) will also affect healthcare delivery in deleterious ways (Frumkin and others, 2007, 2009; Hess and others, 2011; Schwartz and others, 2011). This is because healthcare services are utterly dependent on petroleum products (e.g. medical supplies and equipment, pharmaceuticals, transportation and service delivery, and energy) without which they will come to a halt (Johnstone, 2011c).

In order to mitigate the negative impact of these developments, authorities have increasingly emphasised the need for healthcare reform and a more responsive and better coordinated healthcare system. Healthcare reform, in this instance, has been clarified to include making adjustments to healthcare spending in order to obtain ‘better value for money’. Some argue, however, that healthcare reform is not just a matter of making the system ‘work better’. Callahan suggests, for example, that if the common good is to be achieved, we need to rethink some of our fundamental values about health and healthcare. This, he suggests, is going to require a ‘cultural revolution’ in our thinking about medical technology, progress, dying, death and ageing, because the brutal reality is that ‘there are no reliable or seriously envisioned practical and politically accepted means of managing costs anywhere near the extent that is necessary’ (Callahan, 2009). He further argues that when the costs of the benefits of medical technology begin to exceed what a community or nation can afford, then questions need to be raised about when ‘enough is enough’ and how the point of ‘enough’ might be determined (Callahan, 2009).

The complex of population ageing, the increasing burden of chronic disease, climate change and the depletion of the world’s non-renewable resources raises critical questions about how prepared the nursing profession is to respond to what have been termed the ‘three Rs’ (Wynia, 2007) when faced with ‘extreme events’, that is: rationing (e.g. of medications), restrictions (e.g. on people’s access to and from healthcare services) and responsibilities (of healthcare professionals to continue providing care and treatment when resources are scarce or depleted).

The ethical consequences of these evolving scenarios are likely to be incremental, rather than sudden. Even so, without forward planning encompassing a comprehensive vulnerability analysis, nurses will not be well placed to prepare for or mitigate the tough ethical challenges and choices that lay ahead.

Being ethical in extreme situations can be particularly challenging because it may not be clear what the right thing to do is. Considering ethical quandaries in advance will help mitigate this difficulty. In the meantime, it is timely for attention to be given to the following questions:

‘Everyday’ ethical issues in nursing

As well as having to deal with the procedural issues of ethics—that is, identifying ethical issues and responding to them effectively—and the ‘life and death’ issues commonly associated with the discipline of bioethics, nurses have to grapple with ‘everyday’ ethics. Everyday ethics in nursing derives from the experiences of nurses (and their clients) in day-to-day ‘hands-on’ practice. Unlike the more ‘exotic’ issues of bioethics (discussed above), everyday ethics in nursing concern such things as:

When nurses talk about everyday ethical issues, their conversations are not about the so-called paramount or exotic issues of bioethics (such as euthanasia, abortion and IVF), but about the more fundamental issues of (Johnstone, 2009b):

The moral responsibility of nurses to engage in ‘self-care’ (see Value statement 4 of the Code of ethics for nurses in Australia (Australian Nursing and Midwifery Council, 2008a)) is another ‘everyday’ issue that is finding its way into the conversation of nurses.

The above concerns are just as worthy of attention by nurses and others as are the more ‘exotic’ issues of bioethics. The everyday ethical issues identified constitute an important component of nursing ethics and warrant in-depth consideration in the interests of promoting ethical practice in nursing and related care contexts.