Understanding the basis of ethical professional conduct in nursing requires nurses to have at least a working knowledge and understanding of the language, concepts and theories of ethics. One reason for this, as explained by the English philosopher, Richard Hare (1964: 1–2), is that:

At first glance it might seem cumbersome spending time on clarifying and developing an understanding of the language, concepts and underpinning theories used in discussions and debates on ethics. Upon closer examination, however, it soon becomes clear that such an undertaking is crucial if nurses and their associates are to engage in a meaningful inquiry into what ethics is, what constitutes ‘nursing ethics’ and how, if at all, nursing ethics differs from other fields of ethics, what it means to be an ‘ethical practitioner’, why nurses have an obligation to practise their profession in an ethical manner, and how to be an ethical professional. Furthermore, and not least, how best to proceed with the difficult task of identifying and resolving the many moral problems that nurses (like others in the health care team) will inevitably encounter during the course of their everyday practice.

The terms ‘ethics’, ‘morality’, ‘rights’, ‘duties’, ‘obligations’, ‘moral principles’, ‘moral rules’, ‘morally right’, ‘morally wrong’, ‘moral theory’, to name some, are all commonly used in discussions about ethics. Nurses, like others, may use some of these terms when discussing life events and practice situations that are perceived as having a moral/ethical dimension. These terms are not always used correctly, however, with the unfortunate consequence of communication and discussions about ethical issues sometimes becoming distorted and, as a consequence, giving rise to problems and perplexities that did not exist previously or which could otherwise have been avoided had they been dealt with more competently.

One notable example of the incorrect use of ethical terms can be found in the tendency by some nurses (scholars included) to treat the terms ‘rights’ and ‘responsibilities’ or ‘duties’ as being synonymous, and thus able to be used interchangeably. An example of this is found in the International Council of Nurses (ICN) position statement on the ‘rights and duties of nurses’, adopted at the ICN’s Council of National Representatives meeting in Brazil in June 1983: ‘Nurses have a right to practise within the code of ethics and nursing legislation’ (Keireini 1983: 4, emphasis added). When the nature of rights and duties is examined later, it will become clear that the term ‘right’ in this example should, in fact, read ‘duty’. The implications of confusing the meanings of the terms ‘rights’ and ‘duties’ and treating these two terms as being synonymous will be explored more fully in the chapters to follow.

Another common mistake is the tendency by some nurses to draw a distinction between the terms ‘ethics’ and ‘morality’. They draw a distinction on the grounds that, in their view, morality involves more a personal or private set of values (i.e. ‘personal morality’) whereas ethics is more concerned with a formalised, public and universal set of values (i.e. ‘professional ethics’) (see, for example, Thompson et al 2000; Leininger 1990a). As will be shown shortly, there is, in fact, no philosophically significant difference between the terms ‘ethics’ and ‘morality’ and to distinguish between them is both unnecessary and confusing.

It is acknowledged that most people brought up in a common cultural context share what Beauchamp and Childress (2001: 3) call a ‘common morality’; that is, a set of core norms and dimensions of morality that most people accept as being relevant and important (e.g. respect the rights of others, do not harm or kill innocent people, it is wrong to steal, it is wrong to break promises, and so forth) and about which philosophical debate ‘would be a waste of time’ (Beauchamp & Childress 2001: 3). It would be a mistake, however, to assume or to accept that ‘common morality’ or ‘commonsense morality’ is in and by itself sufficient to enable nurses to deal with the many complex and complicated ethical issues that they will encounter in their practice. As examples to be presented in the following chapters will show, while our ‘ordinary moral apparatus’ may motivate and guide us to behave ethically as people, it is often quite inadequate to the task of guiding us to deal safely and effectively with the many complex ethical issues that rise in nursing and health care contexts. A much more sophisticated moral competency and capability is required than that otherwise provided by a ‘commonsense’ morality.

If nurses are serious about ethics and about conducting themselves ethically in the various positions, levels, and contexts in which they work, then they must engage in a critical inquiry about what ethics is and how it can best be applied in the ‘real world’ of professional nursing practice. It cannot be assumed that just because we know of and use certain ethical terms in our conversations that we know what they mean or that we are using them correctly. As Warnock warns in his classic work Contemporary moral philosophy (1967: 75):

When discussing and advancing debates on ethical issues in nursing and health care it is vital that all parties involved have a shared working knowledge and understanding of the meanings of terms and concepts that are fundamental to the issues being considered. This imperative is captured by the philosophical adage ‘there must first be agreement before there can be disagreement’. The reasoning behind this imperative is that unless there is a shared understanding of core terms and concepts it will be extremely difficult if not impossible to develop insight and understanding of the issues at stake and address if not resolve the disagreements and conflicts that may have arisen in relation to them. For example, if two dissenting parties do not share a common understanding about the nature and content of human rights (what these entail, the moral authority they have, what entities can validly claim human rights, and so forth) they cannot even begin to debate the conditions under which human rights ought to be respected and when they might justifiably be overridden, and to take action accordingly. Similarly, if two dissenting parties do not share a common conception of what nursing ethics is, then they cannot meaningfully debate whether or not nursing ethics ought to be recognised as a distinctive field of inquiry and practice in its own right, or whether nurses are obliged to uphold the standards of ethical conduct developed as a result of focused nursing ethics inquiry.

In developing a shared understanding of core terms and concepts used in discussions and debates on ethical issues it is important for nurses to be aware that, contrary to expectations, many of the terms commonly used in ethical debates are themselves ‘ethically loaded’ and thus, paradoxically, at risk of distorting if not corrupting the debates. The notion of ‘quality of life’ is a good example. Many writers on bioethics assume that when a life ceases to be ‘independent’ it has diminished worth. In instances where quality of life has been a criterion for decision-making at the end stage of life, euthanasia might be considered a right and proper course of action to take. Here the ethically loaded notion of ‘dependence’ imparts a sense of the permissibility of the euthanasia option and limits thought of, say, pursuing a rehabilitation option. It also overrides thought of the possibility that for some people dependence may be quite irrelevant to the notion of a worthwhile life. Kanitsaki (1993, 1994), for example, has shown that in some traditional cultural groups, familial and friendly relationships are characteristically collective and interdependent, and that any thought of individual independence is quite irrelevant to the assessment of ‘a life worth living’.

Poorly or inappropriately defined ethical terms and concepts can seriously impinge upon and limit people’s moral imagination, and the moral options and choices that might otherwise be identified, considered and chosen in the face of moral disagreement, conflict and adversity.

It is appropriate to begin the task of defining commonly used ethical terms and concepts by first examining the terms ‘ethics’ and ‘morality’, and clarifying from the outset there is no philosophically significant difference between the terms ‘ethics’ and ‘morality’. If a distinction is to be drawn between these two terms it is one that is based on etymological grounds (the study of the origin of the words), with ‘ethics’ coming from the ancient Greek ethikos (originally meaning ‘pertaining to custom or habit’), and ‘morality’ coming from the Latin moralitas (also originally meaning ‘custom’ or ‘habit’). This means that the terms may be used interchangeably, as they are in the philosophic literature and in this work. With respect to deciding which terms should be used in ethical discourse (i.e. whether to use the term ‘ethics’ or the term ‘morality’), this is very much a matter of personal preference rather than of philosophical debate, noting, however, that the terms ethics and morality have come to refer to something far more sophisticated than ‘custom’ or ‘habit’, as will soon be shown.

Having clarified that there is no philosophically significant difference between the terms ‘ethics’ and ‘morality’, it now remains the task here to define what ‘ethics’ is.

For the purposes of this discussion ethics is defined as a generic term that is used for referring to various ways of thinking about, understanding and examining how best to live a ‘moral life’ (Beauchamp & Childress 2001). More specifically, ethics involves a critically reflective activity that is concerned with a systematic examination of living and behaving morally and ‘is designed to illuminate what we ought to do by asking us to consider and reconsider our ordinary actions, judgments and justifications’ (Beauchamp & Childress 1983: xii). For example, a nurse may make an ‘ordinary’ moral judgment that abortion is wrong and conscientiously object to assisting with an abortion procedure. Whether her conscientious objection ought to be respected, however, requires a critical examination of the bases upon which the nurse has made that judgment and a consideration of the justifications (moral reasons) she has put forward to support the position she has taken.

Ethics, as it is referred to and used today, can be traced back to the influential works of the Ancient Greek philosophers Socrates (born 469 BC), Plato (born 428 BC) and Aristotle (born 384 BC). The works of these ancient Greek philosophers were especially influential in seeing ethics established as a branch of philosophical inquiry which sought dispassionate and ‘rational’ clarification and justification of the basic assumptions and beliefs that people hold about what is to be considered morally acceptable and morally unacceptable behaviour. Ethics thus evolved as a mode of philosophical inquiry (known as moral philosophy) that asked people to question why they considered a particular act right or wrong, what the reasons (justifications) were for their judgments, and whether their judgments were correct. This view of ethics remains an influential one and, although the subject of increasing controversy over the past two decades, retains considerable currency in the mainstream ethics literature.

It is important to clarify that ethics has three distinct ‘sub-fields’, namely: descriptive ethics, metaethics and normative ethics. Descriptive ethics is concerned with the empirical investigation and description of people’s moral values and beliefs (i.e. values and beliefs concerning what constitutes ‘right’ and ‘wrong’ or ‘good’ and ‘bad’ conduct). Metaethics, in contrast, is concerned with analysing the nature, logical form, language and methods of reasoning in ethics (e.g. it gives consideration to meanings of ethical terms such as ‘rights’, ‘duties’, and so on). Normative ethics, in turn, is concerned with establishing standards of correctness by identifying and prescribing certain rules and principles of conduct and developing theories to justify the norms established. Unlike descriptive ethics and metaethics, normative ethics is evaluative and prescriptive (hortatory) in nature. In the case of the latter, ethics inquiry is not so much concerned with how the world is, but with how it ought to be. In other words, it is not concerned with merely describing the world (although, of course, a description of the world is necessary as a starting point for an evaluative inquiry), but rather in prescribing how it should be and providing sound justification for this prescription. Just what is to count as a ‘sound justification’, however, is an open question and one that will be considered in the following chapter. In this book, all three sub-fields are drawn upon in varying degrees to advance knowledge and understanding of ethical issues in nursing and health care.

Bioethics is a relatively new field of inquiry and can be defined as ‘the systematic study of the moral dimensions — including moral vision, decisions, conduct and policies — of the life sciences and health care, employing a variety of ethical methodologies in an interdisciplinary setting’ (Reich 1995a: xxi). The term ‘bioethics’ (from the Greek bios meaning ‘life’, and ethikos, ithiki meaning ‘ethics’) is a neologism which first found its way into public usage in 1970–71 in the United States of America (Reich 1994; see also Jecker et al 2007). Although originally the subject of only cautious acceptance by a few influential North American academics, the new term quickly ‘symbolised and influenced the rise and shaping of the field itself’ (Reich 1994: 320). Significantly, within 3 years of its emergence, the new term was accepted and used widely at a public level (Reich 1994: 328). Interestingly, it is believed that the term ‘bioethics’ caught on because it was ‘simple’ and because it was amenable to exploitation by the media which had placed a great premium ‘on having a simple term that could readily be used for public consumption’ (Reich 1994: 331).

It is worth noting that initially the term ‘bioethics’ was used in two different ways, reflecting both the concerns and ambitions of two respective academics who, it is suggested, quite possibly created the word independently of each other. The first (and later marginalised) sense in which the word was used had an ‘environmental and evolutionary significance’ (Reich 1994: 320). Specifically, it was intended to advocate attention to ‘the problem of survival: the questionable survival of the human species and the even more questionable survival of nations and cultures’ (Potter 1971 — cited by Reich 1994: 321). In short, it advocated long-range environmental concerns (Reich 1995b: 20). Reich (1994: 321–2) explains that the key objective in creating this term was:

The other competing sense in which the word ‘bioethics’ was used referred more narrowly to the ethics of medicine and biomedical research. The primary focus of this approach was (Reich 1995b: 20):

Significantly, it was this latter sense which ‘came to dominate the emerging field of bioethics in academic circles and in the mind of the public’ — and which remains dominant today (Reich 1994: 320). There are a number of complex reasons for this, not least, the climate at the time which saw the rise of the civil rights movement (including women’s rights and the legal right to abortion which helped to keep bioethical issues ‘before the public’). Given the significant shift in social and moral values that was occurring at the time, however, it is perhaps not surprising that this essentially medical/biomedical sense of bioethics prevailed (Jonsen 1993; Singer 1994). For instance, it is now almost certain that the ideas behind the development of the field of bioethics in its medical/biomedical sense had been simmering for almost a decade before the field was eventually named (Jonsen 1993: S3; see also Jecker et al 2007). Notable among the events inspiring the development of the field were: the dialysis events of the early 1960s, the publication in 1966 of Henry Beecher’s legendary and confronting article on the unethical design and conduct of 22 medical research projects, the heart transplant movement, and later the now famous 1975 Karen Ann Quinlan case (Beecher 1966; Jonsen 1993; Singer 1994).

Today, the dominant concerns of mainstream Western bioethics are still essentially medically orientated, with the most sustained attention (and, it should be added, the most institutional support) being given to examining the ethical and legal dimensions of the ‘big’ issues of bioethics, such as abortion, euthanasia, organ transplantation (and the associated issue of brain-death criteria), reproductive technology (e.g. in vitro fertilisation [IVF], genetic engineering, human cloning, and so forth), ethics committees, informed consent, confidentiality, the economic rationalisation of health care, and research ethics (particularly in regard to randomised clinical trials and experimental surgery). Not only has mainstream bioethics come to refer to and represent these issues, but, rightly or wrongly, has given legitimacy to them as the most pressing bioethical concerns of contemporary health care across the globe.

It is alleged that Potter (one of the authors of the term ‘bioethics’) was himself very frustrated with this narrow conception of bioethics and is reported as responding that ‘my own view of bioethics calls for a much broader vision’ (Reich 1995b: 20). Indeed, Potter feared (prophetically as it turned out) that ‘the Georgetown approach would simply reaffirm medical professional inclination to think of issues in terms of therapy versus prevention’ (Reich 1995b: pp 20–1). Whereas Potter viewed bioethics as a ‘new discipline’ (of science and philosophy) emphasising a search for wisdom, the Georgetown group saw bioethics as an old discipline (applied ethics) to resolve concrete moral problems; that is, ‘ordinary ethics applied in the bio-realm’ (p 21).

It has been claimed that ‘bioethics is a native-grown American product’ reflecting distinctively American concerns and offering distinctively American solutions and resolutions to the bioethical problems identified (Jonsen 1993, S3–4). Whatever the merits of this claim, there is little doubt that bioethics in its medical/biomedical sense has become an international movement. This movement (propelled along by a variety of processes) has witnessed a number of spectacular achievements, including:

The medical/biomedical senses of the term ‘bioethics’ have indeed dominated intellectual and political thought over the past three to four decades. Nevertheless, there are signs that this dominance has been called into question and is slowly changing as more attention is given to such issues as environmental ethics, climate change, and the relationship between health and human rights. (See, for example, the introductions to the second edition [edited by Reich 1995a] and the third edition [edited by Post 2004] of the Encyclopedia of Bioethics; the landmark work of Jonathan Mann and associates on the fundamental relationship between health and human rights [Mann 1996, 1997; Mann et al 1999; Anand et al 2004; Gruskin et al 2005]; and the rise of the ‘new’ public health ethics [see, for example, Beauchamp & Steinbock 1999; Beyrer & Pizer 2007; Daniels 2006; Powers & Faden 2006].) At present, there is considerable room to speculate that in the not too distant future the term ‘bioethics’ might once again hold an environmental, evolutionary and humanitarian significance, and have a much broader focus than it has up until now.

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 ultimate purpose) — all of which have been comprehensively articulated in the nursing literature (too vast to list here). In this regard, then, contrary to popular belief, nursing ethics is not synonymous with (and indeed is much greater than) an ethic of care, although an ethic of care has an important place in the overall moral scheme of nursing and nursing ethics. Unlike other approaches to ethics, nursing ethics recognises the ‘distinctive voices’ that are nurses, and emphasises the importance of collecting and recording nursing narratives and ‘stories from the field’ (Benner 1991, 1994; Bishop & Scudder 1990; Parker 1990). Collecting and collating stories from the field are regarded as important since issues invariably emerge from these stories that extend far beyond the ‘paramount’ issues otherwise espoused by mainstream bioethics. Analyses of these stories tend to reveal not only a range of issues that are nurses’ ‘own’, as it were, but a whole different configuration of language, concepts and metaphors for expressing them. As well, these stories often reveal issues otherwise overlooked in mainstream bioethics discourses. Given this, nursing ethics can also be described as methodologically and substantively, inquiry from the point of view of nurses’ experiences, with nurses’ experiences being taken as a more reliable starting point than other locations from which to advance a rich, meaningful and reliable system and practice of nursing ethics.

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 theoretical considerations (what Beauchamp & Childress [2001: 400] call a ‘coherentist’ approach, and Benjamin [2001] calls a ‘pragmatic reflective equilibrium’ approach), nursing ethics at its most basic could thus also be described as a practice discipline which aims to provide guidance to nurses on how to decide and act morally in the contexts in which they work.

The project of nursing ethics has many aspects to its nature and approach. Among other things, it involves nurses engaging in ‘a positive project of constructing and developing alternative models, methods, procedures [and] discourses’ of nursing and health care ethics that are more responsive to the lived realities and experiences of nurses and the people for whose care they share responsibility (adapted from Gross 1986: 195). In completing this project, nursing ethics has had — and continues to have — the positive consequence of allowing other ‘weaker’ viewpoints (including those of patients and nurses themselves) to emerge and be heard. In this respect, nursing ethics is also intensely political — although, it should be added, no more political than other role-differentiated ethics.

As in the case of moral philosophy, nursing ethics inquiry can be pursued by focusing on one or all of the following:

It is important to remember (as discussed in the 3rd edition of this work [Johnstone 1999a]) that nursing ethics has not always enjoyed the status that it has today. Its development, legitimation and recognition as a distinctive field of inquiry is testimony to the reality that nursing ethics is both necessary and inevitable. It is 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 most powerful (be they religious, legal, social, political or other in nature) (Churchill 1989: 30). Furthermore, as Churchill (1989: 31) writes, ‘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’.

In regard to the inevitability of nursing ethics, as Churchill (1989: 31) points out, the ‘practice of a profession makes those who exercise it privy to a set of experiences that those who do not practice lack’. By this view, those who practise nursing are privy to a set of experiences (moral experiences included) that others who do not practise nursing lack. So long as nurses interact with and enter into professional caring relationships with other people, they will not be able to avoid or sidestep the ‘distinctively nursing’ experience of deciding and acting morally while in these relationships. It is in this respect, then, that nursing ethics can be said to be inevitable.

To further our understanding on what ethics (and its counterparts bioethics and nursing ethics) is, it would be useful to also give some attention to what ethics is not. For instance, ethics is not the same as law or a code of ethics. Neither is ethics something that can be determined by public opinion, or following the orders of a supervisor or manager. Failing to distinguish ethics from these kinds of things could result in otherwise avoidable harmful consequences to people in health care domains.