Ethical principles are general standards of conduct that make up an ethical system. To say that a principle is ‘ethical’ or ‘moral’ is merely to assert that it is a behaviour guide which ‘entails particular imperatives’ (Harrison 1954: 115). In this instance the imperatives involve specification (in the form of prescriptions and proscriptions) that some type of action or conduct is either prohibited, required or permitted in certain circumstances (Solomon 1978: 408). By this view, an action or decision is generally considered morally right or good when it accords with a given relevant moral principle, and morally wrong or bad when it does not. To illustrate how this works, consider the action of making a measurement using a ruler. If the line you have drawn measures the desired length of, say, 12 cm — as measured against your ruler — you would judge the length as ‘correct’. If, however, the line you have drawn is only 10 cm long — not the desired 12 cm — you would judge the length to be ‘incorrect’. By analogy, principles also function like rulers, insofar as they provide a standard against which something (in this case, actions) can be measured. For example, if an action fails to ‘measure up’ to the ultimate standards set by a given principle, we would judge the action to be ‘incorrect’ or, more specifically, morally wrong. If, however, an action fully measures up to the ultimate standards set by a given principle, we would judge the action to be ‘correct’ or morally right. The next question is: What are these moral principles against which actions can be measured?

Moral principles commonly used in discussions on ethical issues in nursing and health care include the principles of autonomy, non-maleficence, beneficence and justice. It is to examining the content, prescriptive force and application of these principles that this discussion now turns.

Moral principles are not the only entities that make up an ethical system or ethical framework for guiding conduct. Moral rules also have a place in guiding and ‘warranting’ ethical conduct. Like moral principles, moral rules function by specifying that some type of action or conduct is either prohibited, required or permitted (Solomon 1978: 408–9). What distinguishes a moral rule from a moral principle in certain contexts is its structure and nature. Moral principles, for instance, tend to be regarded as providing the content of morality, and the bases or the ‘parent’ forms from which general moral truths (insofar as these can be determined) are derived. In application, moral principles incline more towards a general focus. Consider, for example, the broad moral principle of ‘autonomy’. In general, the principle demands that persons should be respected as autonomous choosers, capable of judging what is in their own best interests. As such, rational persons should be free to act as they wish provided their actions do not violate the moral interests of others.

Moral rules, on the other hand, stand as being merely derivative of moral principles and theories and, in application, are much more particular in their focus. Although it is difficult to draw a firm distinction between moral rules and moral principles, it is generally recognised that moral rules have different force, sanctioning power, conditions of existence, scope of application and level of concreteness from moral principles (Solomon 1978). An example of a moral rule would be the demand, say, to ‘always tell the truth’ or ‘never tell a lie’. Thus, if a patient asks an attending health care professional a question concerning a diagnosis and proposed treatment, the health care professional could be said to be obliged to give the information the patient has requested. The apparent ‘obligation’ here finds its force not just from the moral rule ‘always tell the truth’, but from the moral principle of autonomy which demands that rational people be respected as autonomous choosers, and be given the information required to make an informed and intelligent choice.

Another example can be found in a set of rules that prescribe such things as ‘do not kill others’, ‘do not cause pain and suffering to others’, ‘do not affect detrimentally the physical and mental health of others’, and so forth. The apparent obligations here find their force not just from the rules stated, but from the moral principle non-maleficence which prescribes ‘do no harm’.

In order for a particular moral rule (or set of moral rules) to be justified, it must be fully derived from and reducible to established parent principles of morality.

In summary, moral rules derive from moral principles, and as such have only prima-facie force (i.e. they can be overridden by stronger moral claims). Given their prima-facie nature, moral rules cannot override the moral principles from which they have been derived. To accept that they could would be to suggest, somewhat paradoxically, that derived rules could meaningfully conflict with parent principles — which, of course, is absurd. The relationship between particular moral judgments, moral rules, moral principles and moral theories is shown in Figure 3.1.

The question of moral rules is an important one for nurses, particularly as it relates to the broader issue of professional codes of conduct, an issue that will become clearer in the following chapters.

In considering ethical principlism it is important to be aware of a number of difficulties that can arise when appealing to the ethical principles described. For example, problems commonly associated with ethical principlism include:

The issue of moral uncertainty, moral dilemmas and moral disagreements in regard to the selection, interpretation and application of ethical principles will be explored further in the chapters to follow.

Moral rights (to be distinguished here from human rights, legal rights, institutional rights, civil rights, etc) generally entail claims about some special entitlement or interest which ought, for moral reasons, to be protected. The kinds of interests for which protection might be sought include, for example, life, freedom, happiness, privacy, self-determination, fair treatment and bodily integrity. The language used in asserting rights typically involves expressions such as: ‘I have a right to …’, ‘It’s your right to …’, ‘They have a right to …’, and so on. A rights claim is generally accepted as a sound moral reason for taking moral action.

There is no single thesis of moral rights. The following is a brief overview of some of the better known classical and contemporary theories concerning the existence of moral rights and the conditions under which they can be validly claimed.

In discussing rights it is important to keep in mind at least six central problems that can arise when dealing with rights claims. First, rights and interests can seriously compete and conflict with one another. For example, a patient’s right to life could seriously compete or conflict with another patient’s right to life in a situation involving scarce medical resources; or a nurse’s conscientious refusal to assist with an abortion procedure could conflict with a patient’s right to have an abortion and to receive care following the procedure. In such instances there may be no easy solution to the conflict of interests at hand.

Second, it may be difficult to establish the extent to which a person’s rights claim entails a correlative duty. For example, if someone claims a right to life, who or what has the corresponding duty to respond to that claim? Does it fall to the health professional, or to family, friends, the hospital, the state or another entity? There may be no satisfactory answer to this question.

Third, there may be disagreement about which entities have rights. For example, some might argue that brain-dead people, anencephalic babies, the intellectually impaired and babies do not have moral rights, while others might argue that they do. Again there may be no satisfactory resolution to this type of disagreement.

Fourth, it may be very difficult to try and satisfy the rights claims of all people equally. For instance, if there is a genuine lack of resources, it may be impossible to satisfy all rights claims. Once again, we are left, unhappily, with an unresolved moral problem.

Fifth, it may be very difficult to determine what counts as a responsible and irresponsible rights claim and the conditions under which an irresponsible rights claimant might forfeit his or her entitlements (have their rights claims nullified).

Sixth, and more seriously, is the controversial claim that moral rights theory is not a complete theory at all, but only ‘a piece of a more general account of what makes a claim valid [and justified]’ — a ‘partial framework’ as it were (Beauchamp & Childress 2001: 361). By this view, rather than being a comprehensive theory, a moral rights perspective is at best only an account of ‘minimal and enforceable rules that communities and individuals must observe in their treatment of persons’ (Beauchamp & Childress 1994: 76, emphasis added).

On account of these and other difficulties (not least, the inherent adversarial nature of rights claims and entitlements), some have sought to avoid a moral rights perspective altogether, or at least to ‘replace the language of rights’ (Beauchamp & Childress 2001: 362). (For example, when referring to people’s moral entitlements, instead of using ‘rights’ language, some writers use such terms as ‘interests’, ‘welfare’, ‘wellbeing’, and so on.) Others, however, defend the use of rights language despite the theoretical weaknesses of a moral rights perspective. Beauchamp & Childress, for example, contend that (p 362):

Others have taken a similar stance adding that rights discourse has a ‘high reputation’ and, for all its weaknesses, continues to enjoy ‘pervasive popularity’ in the world at large (Campbell 2006: 1, 5). Reasons for the success of rights discourse have been identified by Campbell as involving the strong association it has with the language of:

The issue of moral rights is an important one for nurses — particularly as the issue relates to patients’ rights and the patients’ rights movement, and also to the relationship between health and human rights that has been receiving increasing attention in recent years. As these are substantial issues in their own, they are considered separately in Chapter 6 of this book (see also Realizing Rights: the Ethical Globalization Initiative, which can be viewed at http://www.realizingrights.org/).

The term ‘virtue’ (from the Latin virtus meaning ‘manliness’, courage from vir meaning ‘man’) denotes the quality or practice of moral excellence. As an ingredient of moral theory, it can be defined as:

There are many examples of ‘the virtues’ (see, e.g. the 52 virtues listed by the Virtues Project™@www.virtuesproject.com/, and which are presented as core ingredients that people may use to ‘create a culture of character’). Some examples of the ‘better known’ moral virtues include: altruism, caring, compassion, cooperation, courage, diligence, empathy, excellence, fairness (justice), forgiveness, friendship, generosity, kindness, love, loyalty, personal integrity, reliability, respectfulness, sympathy, trustworthiness, and wisdom (Beauchamp & Childress 2001; Hursthouse 2007; Kruschwitz & Roberts 1987; Pellegrino 1995; van Hooft 2006).

Consistent with a virtue theory account of ethics is a nursing articulated ‘ethic of care’ — long regarded by many nurse theorists as the moral foundation, essence, ideal and imperative of nursing (Benner & Wrubel 1989; Bowden 1994; Carper 1986; Cooper 1991; Fry 1989a; Gaut 1992; Leininger 1990a; Roach 1987; Watson 1985). Despite this, there has been mounting criticism in recent years about the place of ‘care’ in nursing ethics. These criticisms have ranged from describing an ethic of care as being ‘hopelessly vague’ and as ‘obscuring more than it promotes’ (Allmark 1995), to rejecting that care is a virtue at all (Curzer 1993). Still others denigrate care as an untenable form of ‘subjugation’ of women on account of its apparent ‘sexist service orientation’ that could see women (nurses) carrying a disproportionate ‘burden of care’ in a society (or a system) that is, for the most part, careless (Puka 1989). A brief response to some of these criticisms is warranted here.

First, as just demonstrated, a reflective articulation of an ethic of care in relation to the moral ends of nursing helps to clarify the precise behaviours expected of a ‘good’ nurse. It not only prescribes ‘do good’, but it describes what those ‘goods’ are (the promotion of health, healing and wellbeing, and the alleviation of suffering), and how to achieve them (through an integration of expert and virtuous caring comprising a range of ‘healing promoting behaviours’). Second, given the mutually beneficial nature of ‘virtuous caring’ (it has demonstrable positive outcomes for both the receiver and the giver of authentic virtuous care), there is room to suggest that ‘caring’ that is unjustly burdensome is not only not ‘virtuous caring’ but not ethical. Arguments against ‘virtuous caring’ are thus not correctly aligned at the right target; they are, as it were, ‘attacking a straw man’. Third, the criticisms are not convincing. For instance, in the case of the criticism that an ethic of care could be unduly burdensome on women (nurses), it is not immediately clear why it would be any more burdensome than say an obligation-based theory of ethics. As the example of the Biblical story of Abraham demonstrates (Abraham came close to sacrificing his only son to fulfil his duty of obedience to God), ‘doing one’s duty’ can, in some circumstances, be an extremely burdensome thing to do and further may not be able to be done without sacrificing something of moral importance. Further, to suggest that nurses might in some way become enslaved or ‘subjugated’ by an ethic of care, seems to imply erroneously that (and, it must be added, perpetuate the patriarchal myth that) nurses qua nurses lack the discretion and moral competence necessary to decide for themselves what moral standards they will adopt and uphold; in short, it seems to suggest, incorrectly in my view, that nurses will just ‘follow slavishly’ an ethic of care. Finally, these criticisms seem to overlook that an ethic of care is, paradoxically, protective of its practitioners in that it rejects symbiotic (over) emotional involvement with ‘the other’, emphasising instead moral virtue (characterological excellence) as its foundation (Gastmans et al 1998: 54–7).

Virtue ethics, like other theories of ethics, is not free of difficulties. Key among these are: the ‘circularity of justification’ in virtue theory (virtuous persons do what is good, the good is what virtuous persons do); the inability of virtue theory to explain adequately its force as a moral action guide (i.e. compared with other obligation-based theories that can rely on moral rules, principles and maxims to justify moral conduct); and the high expectations virtue theory imposes on people to be ‘good’ (while a good many of us can be conscientious in our actions, few of us can be ‘exemplary’ [Pellegrino 1995: 262–3]). These difficulties, however, may be more a product of the adversarial nature of philosophical inquiry and its use to critically examine and raise objections to virtue theory, than a problem with virtue ethics itself. For instance, given the distinctive non-rational quality of the moral virtues, it seems odd to suggest that virtuous actions require ‘justification’ (how does one ‘justify’ an inclination to be kind towards another, or to be fair? How does one ‘justify’ an act of saintliness or heroism?). Similarly, it seems odd to expect that virtue theory can be reduced to a set of justificatory rules, principles and maxims (noting that, what makes the virtues what they are is their spontaneous and unconditional expression beyond that otherwise required by rules, principles and maxims). There is room here to suggest that to ‘justify’ the virtues in a rational philosophical sense is to do violence to them and to all that they represent. Finally, it seems odd to suggest that expecting people to be ‘decent’ and ‘morally excellent’ human beings is ‘too high an expectation’. Ethics is precisely about expecting people to strive to achieve the highest ideals of morality and to engage in morally excellent conduct. Virtue ethics is no different in this regard. That people may not achieve such an ideal is no reason to abandon ethics, and it is no reason to abandon virtue ethics either.

It is becoming increasingly accepted that while virtue cannot stand alone, it can be (and should be) ‘related to other ethical theories in a more comprehensive moral philosophy than currently exists’ (Pence 1984: 282; see also Pellegrino 1995: 254). As Beauchamp and Childress (1994: 66) conclude, the virtues have ‘a special place in the moral life’. They are mostly compatible with traditional obligation-based theories (e.g. principles and rules) and where there exists a correspondence between them, even though ‘rough and imperfect’, they tend to be mutually reinforcing of each other. For example, respect for the principle of autonomy, requires the virtue of respectfulness; commitment to and upholding the principle of beneficence, requires the virtue of benevolence; and so on (Beauchamp & Childress 2001: 39).

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 be asked 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. 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). This is ‘because and only because it is commanded by God’ (Frankena 1973).

There are many examples of deontological ethics influencing decision-making in health care domains. For example, Jehovah’s Witnesses are well known for their refusal of life-saving blood transfusions, on the grounds that to accept such treatment would be tantamount to violating God’s command that, according to their beliefs, prohibits taking blood (Fry & Johnstone 2008). Another example can be found in a deontological adherence by some physicians 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 & Jecker 1995).

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 good will. 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 (non-moral) 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 only act 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’.

According to teleological theory (also known as consequentialism) actions can only be judged right and/or good on the basis of the consequences they produce. In this respect, teleological ethics denies everything that deontological ethics 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 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 people’s collective and overall welfare and interests. 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 (Singer 1993; Smart & Williams 1973). To put this 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 1962b). 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 autonomy and individual preferences as being of intrinsic value rather than the maximisation of happiness per se. This is because, as Beauchamp and Childress (2001: 342) explain, what is intrinsically valuable is what individuals prefer to obtain, and utility is thus translated into maximising ‘the overall satisfaction of the preferences of the greatest number of individuals’.

Although not without difficulty, preference utilitarianism is also considered more plausible since 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.

Common to all theoretical perspectives are the imperatives they impose for behaving in ways that respect the significant moral interests of others. It is generally accepsted within moral philosophy that moral theories, moral principles, and moral rights all provide sound moral reasons for deciding and acting (behaving) in certain ways towards others and for explaining why we should act morally. For example, the moral principle of autonomy and the moral right to informed consent both seem to provide strong reasons (‘moral warrants’) for giving information to patients/clients and why; that is, to enable them to make prudent and intelligent choices about their care and treatment. More than this, they impose a moral duty on us to do so. To understand what this means and how duties (and their counterparts, obligations) ‘bind’ us to be moral it would be useful here to explain what duties and obligations are and how they work.