The first type of moral problem to be considered here is that of general ‘unpreparedness’ to deal appropriately and effectively with morally troubling situations. What invariably happens here is that a nurse (or other health professional) enters into a situation without being sufficiently prepared to deal with the moral complexities of that situation specifically. The nurse (or other health professional) may lack the requisite moral knowledge, moral imagination, moral experience and moral wisdom otherwise necessary to be able to deal with the moral complexities of the situation at hand (this could also count as moral incompetence or moral impairment). When eventually faced with a particular moral problem, the nurse acts in bad faith by pretending that the situation at hand is one which can be handled ‘with one’s given moral apparatus’ (Lemmon 1987: 112). The room for moral error here is considerable.

To illustrate the seriousness of moral unpreparedness, consider the analogous situation of clinical unpreparedness. A nurse who is not educated in the complexities of, say, intensive care nursing, but who is nevertheless sent to ‘help out’ and care for a ventilated patient in intensive care, would not only be inadequate in this role, but could even be dangerous. Such a nurse might not have the learned skills necessary to detect the subtle changes in a sedated patient’s condition — changes indicating, for example, the need for more sedation, or the need to perform tracheal suctioning, or the need to increase the tidal volume of air flow or oxygen administration. Neither might this nurse be able to distinguish the many different alarms that can go off on the high-tech equipment being used to give full life support to the patient, or to detect any malfunctioning of this sophisticated equipment. Without these skills, a nurse working in intensive care would be likely to place the life and wellbeing of the patient at serious risk.

The argument of the seriousness of unpreparedness also applies to the complexities of sound ethical reasoning and ethical health care practice generally. Such a nurse, left to deal with a morally troubling situation, would not only be inadequate in that role but, as the intensive care example shows, his or her practice could be potentially hazardous. Without the learned moral skills necessary to detect moral problems and to resolve them in a sound, reliable and defensible manner, an unprepared nurse, no matter how well intentioned, could fail to correctly detect moral hazards in the workplace, and therefore fail to act or respond in a way that would prevent adverse moral outcomes from occurring.

The kinds of preventable adverse moral outcomes or ‘near misses’ that can occur as a result of nurses’ (and other allied health professionals’) moral unpreparedness to deal appropriately and effectively with moral problems in health care contexts are well documented in the nursing, bioethical, legal and other related literature. To give just one example, consider the notorious case of the Chelmsford Private Hospital in Sydney, Australia. In this case, many people were left permanently damaged and scarred — some even died — as a result of receiving deep sleep therapy (DST) prescribed by Dr Harry Bailey, a consultant psychiatrist, who later suicided in connection with the scandal that was eventually uncovered (Bromberger & Fife-Yeomans 1991; Rice 1988). It is now known that approximately one thousand patients were ‘treated’ with DST at this hospital. It is also known, as revealed as early as 1977 by the current affairs television program 60 Minutes, that many of these patients did not receive the standard of care and treatment they were entitled to receive. Among other things — including the deaths of seven people between 1974 and 1977 — the 60 Minutes program revealed that ‘recognised standard precautions for the safety of patients were not taken; and that patients received the treatment without their consent’ (Bromberger & Fife-Yeomans 1991: 142). In the Chelmsford Royal Commission that was eventually established in 1988 to ‘examine the provision of Deep Sleep Therapy and the administration of Chelmsford Private Hospital’, it was confirmed that:

Nursing care was also seriously substandard. In one notable case, the nursing care had been so negligent that a patient developed severe decubitus ulcers between her knees, which became ‘glued’ together as though they had been skin-grafted. The former patient recalled:

Bromberger and Fife-Yeomans (1991: 94) comment that the patient ‘still retains the scars on the inside of her knees’.

Another example of the substandard nursing care that was provided (or more to the point, not provided) can be found in the experiences of another patient, Barry Hart, outlined in the following statement read to the New South Wales Parliament in 1984:

One of the troubling things about the whole Chelmsford scandal is that rumours about Dr Bailey’s unscrupulous practices had been circulating for years, yet nothing was done about it (Bromberger & Fife-Yeomans 1991: 176). Equally disturbing is the fact that it was not until 1988 — 24 years after the investigated death of the first ‘deep sleep’ patient, and only after ‘treatment’ had led to the deaths of 24 patients — that a Royal Commission was set up to investigate the allegations concerning the patient abuse that was subsequently proved to have occurred at Chelmsford Private Hospital (Bromberger & Fife-Yeomans 1991: 162). Significantly, in the Royal Commission of Inquiry that was conducted, and in the report on its findings, it was revealed that between 1963 and 1979 only two nurses took action in an attempt to expose the unscrupulous practices they had observed ( Report of the Royal Commission into Deep Sleep Therapy 1990: 127). There is room to speculate here that had nursing personnel been better prepared to recognise and respond effectively to violations of professional ethical standards, the trauma and suffering experienced by the patients at Chelmsford could have been reduced considerably, if not avoided altogether.

Not all adverse moral outcomes occurring in health care contexts are as ethically dramatic as those that occurred in the Chelmsford Private Hospital case, however. Preventable adverse moral outcomes can and do occur on a much more commonplace level in the health care arena, as examples to be given in the following chapters of this book will show.

A second type of problem that nurses often encounter is that of what I shall call ‘moral blindness’. A morally blind nurse (or other health professional) is someone who, upon encountering a moral problem, simply does not see it as a moral problem. Instead, they may perceive it as either a clinical or a technical problem. A tendency by health professionals to sometimes ‘translate ethical issues into technical problems which have clinical solutions’ was recognised over three decades ago (Carlton 1978: 10), and persists in various forms to this day (the surgery ban on smokers, to be considered shortly in this section, is an example).

Moral blindness can be likened, in an analogous way, to colour blindness. Just as a colour-blind person fails to distinguish certain colours in the world, a morally blind person fails to distinguish certain ‘moral properties’ in the world. Perhaps a better example can be found by appealing to a set of imageries commonly associated with Gestalt psychology and theories on the nature of perception. What I particularly have in mind here are the two drawings which are popularly presented in psychology texts to demonstrate certain perceptual phenomena, including perceptual organisation and the influence of context on the way in which an object is perceived.

The first of these drawings (Figure 5.1) depicts what initially appears to be a white vase or goblet against a black background; after a more sustained glance, the drawing changes (or rather, one’s perception ‘shifts’) and what is perceived instead are two black facial profiles separated by a white space. Some people see the alternating vase–face images relatively quickly and easily, while others struggle to shake off what for them remains the dominant image (i.e. either the vase or the faces).

The second ambiguous drawing (Figure 5.2) depicts what can be seen as either an unsophisticated-looking old woman or a very sophisticated-looking young woman. As with the vase–face drawing, some people see the alternating old woman–young woman images relatively easily, while others literally get ‘stuck’ with a dominant perception of either the young woman or the old woman.

Psychologists claim, however, that people’s perceptions can be altered by context — in this instance, by showing photographs before the ambiguous drawings are viewed. They claim that, on an initial viewing of the second drawing, 65 per cent report seeing the young woman first. If subjects are shown photographs of an old woman before seeing the drawing, however, almost all see the old woman first. The same ‘reversals’ can be achieved by conditioning subjects with photographs to see the young woman first (Atkinson et al 1983: 147).

I am not here attempting to present an elaborate theory of moral perception but rather trying to illustrate what I believe is a common and potentially morally risky phenomenon in health care contexts: that of impaired moral perception. There is, I think, room to suggest that health professionals (including nurses) are sometimes so conditioned by the ‘clinical imagery’ (context) around them that, when they do encounter a bona fide moral problem, it tends to be perceived not as a moral problem, but as a clinical or a technical problem and, as such, one requiring a clinical solution, not a moral solution. Some health professionals have a healthy perception of the alternating moral–clinical images depicted by a given scenario; others, however, remain stuck with a dominant clinical image and do not see the alternative moral image, which for them is less discernible. One unfortunate consequence of this, is that technically correct decisions are sometimes made at the expense of morally correct decisions.

The extent to which clinical perceptions and judgments can dominate over moral perceptions and judgments can be illustrated by the once common practice of defending ‘Do Not Resuscitate’ (DNR) directives (also called ‘Not For Resuscitation’ or NFR directives) on hopelessly or chronically ill patients on medical grounds (‘medical indications’) alone. In the past many doctors and nurses perceived DNR directives as involving a clinical issue, not a moral issue, and, as such, one to be decided by doctors, not ethicists. The clinical–moral Gestalt problem became particularly clear to me at a nursing law and ethics conference in 1988. After presenting a paper on the nature and moral implications of DNR/NFR directives, I was approached by several registered nurses with what became a familiar and distressing comment: ‘My God! I had never thought about it [DNR/NFR] as a moral issue before … What have I done?’; other nurses wanted to challenge or attack the view that DNR/NFR directives involved moral considerations and moral decisions. The then state president (in Victoria) of the Australian Medical Association, Dr Bill McCubbery, was prompted to respond to the issue, and is reported as saying that ‘NFR decisions had to depend on professional judgment’ (Schumpeter 1988: 21).

Today there is a much greater recognition of the moral dimensions of DNR/NFR directives and the degree to which such directives are informed by moral considerations (see the discussion on DNR in Chapter 12 of this book). The once common view that DNR/NFR decisions are based ‘simply’ on medical concerns/indications (not ethical concerns) and are more a matter of ‘good medical judgment’ (rather than — or as well as — sound moral judgment) is rarely advanced in contemporary debate, at least not credibly. Nevertheless, this kind of thinking persists in regard to other issues. For example, in 2001, in a highly publicised surgery ban imposed on smokers by doctors in the Australian state of Victoria, surgeons were reported as defending their stance by arguing that:

The specific treatments banned, in this instance, were reported to include: artery by-passes, coronary artery grafts, lung reduction surgery and lung and heart transplants (Taylor 2001: 4). In 2004 and 2007 respectively, surgeons again defended their ‘right’ to refuse to operate on people who smoked cigarettes (Peters 2007; Peters et al 2004; see also rejoinder by Glantz 2007).

The issue of ‘moral blindness’ among nurses is an important one, since, as with the problem of moral unpreparedness, it could result in otherwise avoidable moral harms occurring. This problem is not insurmountable, however. Just as people can be ‘conditioned’ to see the old woman rather than the young woman in the ambiguous drawing shown in Figure 5.2, so too can nurses and allied health professionals be ‘conditioned’ (or rather educated) to see the moral dimension of an ambiguous scenario which can be perceived as involving either a moral problem or a clinical or technical problem. Arguably, the best way to achieve such a Gestalt moral shift in perception is by appropriate ethics education and reflective ethical practice.

A third type of problem which nurses may encounter is that of ‘moral indifference’. Moral indifference is characterised by an unconcerned or uninterested attitude towards demands to be moral; in short, it assumes the attitude of: ‘Why bother to be moral?’ The morally indifferent person is someone who typically refrains from expressing any desire that certain acts should or should not be done in all comparable circumstances (Hare 1981: 185). An example of a morally indifferent nurse would be a nurse who is both unconcerned about and uninterested in alleviating a patient’s pain, or is unconcerned about or uninterested in the fact that a DNR directive or a directive to perform electroconvulsive therapy (ECT) has been given on an unconsenting patient, or is unconcerned about and uninterested in any form of violation of patients’ rights, for that matter. As well as this, a morally indifferent nurse would probably refrain from expressing a desire that anything should be done about such situations.

The problem of moral indifference in nursing is well captured by Mila Aroskar (1986) in her classic article ‘Are nurses’ mind sets compatible with ethical practice?’. Aroskar (1986: 72) cites the findings of a study undertaken in the late 1970s which showed that nurses tended to defer to institutional norms ‘even when patients’ rights were being violated’. She also points out that, despite the North American nursing profession’s formal commitment to ethical practice (as manifested, among other things, by its formal adoption of various codes and standards of practice), arguments were still widely heard among nurses that ‘ethical practice is too risky and requires a certain amount of heroism on the part of nurses’ (Aroskar 1986: 69). Although written almost two decades ago, Aroskar’s words still apply today. As Jill Iliffe of the Australian Nursing Federation reflects (2002: 1):

The retreat by nurses into moral indifference, while not condonable, is understandable. There are many examples that demonstrate the kinds of difficulties nurses might find themselves in when attempting to conduct morally responsible, professional practice, and the ultimate price that can be paid for taking a moral stand on a matter. One such example concerns the highly publicised United Kingdom case of a registered nurse by the name of Graham Pink. Pink was found guilty of ‘gross misconduct’ by his employing health authority after he publicly exposed unacceptable standards of care (including poor staff–patient ratios) in the hospital at which he worked (Turner 1992, 1990; Tadd 1991). Pink’s ordeal began in 1989 when he wrote to the local health authority detailing his concerns about the substandard care that was being given to elderly residents at the hospital where he worked. The health authority followed up the complaint and agreed that ‘something must be done’ and instructed the hospital ‘to look at’ staffing levels (Turner 1992: 28). When these instructions were not actioned, Pink communicated his concerns in writing to the chief executive of the National Health Service, the health secretary and the prime minister Mrs Thatcher. He received a written reply from the latter two ‘thanking him’ for the information but pointing out that it was ‘a local matter’ (Turner 1992: 28).

Subsequently Pink was persuaded by a member of parliament to allow a selection of his letters to be published in the Guardian newspaper. This action resulted in enormous public support. Pink, meanwhile, was warned ‘not to speak out further’ (Turner 1992: 28). Even though his actions (‘to take appropriate action’) were supported by the United Kingdom Central Council’s Code of Professional Conduct (1984) and advisory document Exercising Accountability (1989) that were in operation at the time, they nevertheless placed him at odds with his employer. Pink was suspended from duty, and the hospital management initiated disciplinary procedures against him. After 1 year of hearings and appeals, Pink was found guilty of gross misconduct and offered a transfer to a community setting. Pink refused this offer, however, and was dismissed by his employer. Summing up the implications of this case, one nurse is reported as commenting: ‘It is difficult to imagine anybody ever speaking out again — they just wanted to get him and they did’ (Turner 1990: 19). Another commentator concludes succinctly: ‘Graham Pink’s experience show[s] that once nurses raise their heads above the parapet they may not be far from disciplinary action’ (Turner 1990: 19).

Although this case occurred several years ago, the lessons it provides remain current and are indicative of the difficulties nurses worldwide often face when trying to deliver ethically responsible care (see also Chapter 13 of this book). We all know (and have possibly personally experienced) the forces that can be brought to bear upon a nurse who takes a moral position which conflicts with established hospital norms and etiquette. It is then perhaps understandable (even though not excusable) that nurses become morally indifferent to the violations of patients’ rights and other unjust practices in health care domains. Compounding this situation, institutional and legal constraints may make it very difficult for nurses to act morally (Johnstone 2002a, 1994). The price paid for acting morally or for taking a moral stand can be intolerably high, as other examples to be given in the chapters to follow will show. What this signifies, however, is not that nurses should abandon the demands of morality; rather, they should seek ways in which morality’s demands can be upheld safely and effectively.

A fourth type of moral problem which nurses might encounter, and which is similar to moral indifference, is that of ‘amoralism’, which is characterised by an absence of moral concern and a rejection of morality altogether (a position significantly different from immoralism, [discussed below] which accepts morality, but violates its demands). An amoral person is someone who refrains from making moral judgments and who typically rejects being bound by any of morality’s behavioural prescriptions and proscriptions. If an amoralist were to ask: ‘Why should I be moral?’, it is likely that no answer would be satisfactory. (For a classic response to the question: ‘Why should I be moral?’, see Nielsen 1989.)

A nurse who is an amoralist would reject any imperative to behave morally as a professional. For example, the amoral nurse might reject that he or she has a moral duty to uphold a patient’s rights. The amoral nurse would also probably claim that it does not make any sense even to speak of things like a patients’ ‘rights’ since moral language itself has no meaning. The amoralist’s position in this respect is analogous to the atheist’s rejection of certain religious terms. The extreme atheist, for example, would argue against uttering the word ‘God’, since it refers to nothing and therefore has no meaning. Such an atheist might also claim that there is no point in engaging in a religious debate on the existence of God, since there is just nothing there to debate. To try and debate the existence of God would be like trying to debate the existence of ‘a black cat in a darkened room when there isn’t one’. The amoralist may argue in a similar way in relation to the issue of morality.

It can be seen that the amoralist’s position is an extreme one, and one which is very difficult to sustain. (Even thieves, who may appear amoral, act on the ‘moral’ assumption that it is ‘good/right’ to steal.) Perhaps the most approximate example that can be given here is that of psychopaths or frontal lobe damaged persons who simply lack all capacity to be moral — an issue that has been comprehensively explored in the neuroethics literature (see, for example, Damasio 1994, 2007; Gellene 2007; Koenigs et al 2007; Strueber et al 2007). If amoralism is encountered in health care contexts, it is likely that very little can be done, morally speaking, to deal with it. The only recourse in dealing with the amoral health professional would be to appeal to non-moral censuring mechanisms such as legal and/or professional disciplinary measures.

At its most basic, immoral conduct (also known as moral turpitude and moral delinquency) can be defined as any act involving a deliberate violation of accepted or agreed ethical standards. Moral turpitude (a notion which has received more stringent attention in the United States than in Australia) has been defined specifically as:

Moral delinquency, in turn, is taken here as referring to any act involving moral negligence or a dereliction of moral duty. As in the above definitions, moral delinquency in professional contexts entails a deliberate or careless violation of agreed standards of ethical professional conduct.

Accepting the above account, an immoral nurse can thus be described as someone who knowingly and wilfully violates the agreed norms of ethical professional conduct or general ethical standards of conduct towards others. Judging immoral conduct, by this view, would require a demonstration that the accepted ethical standards of the profession were (1) known by an offending nurse, and (2) deliberately and recklessly violated by that nurse. There are many ‘obvious’ examples of immoral conduct by nurses. These include: the deliberate theft of patients’ and/or clients’ money for personal use; the sexual, verbal and physical abuse of patients/clients; xenophobic behaviours (including racism, sexism, ageism, homophobia and a range of other unjust discriminatory behaviours); participation in unscrupulous research practices; and other morally unacceptable behaviours, examples of which are given throughout this book.

It should be noted that regardless of whether an act involving the violation of agreed professional or general ethical standards results in a significant moral harm to another, it would still stand as an instance of immoral conduct. For example, a nurse who knowingly and recklessly breaches a patient’s/client’s confidentiality would have committed an unethical act even if the breach in question did not result in any significant moral harm to the patient/client.

A sixth type of moral problem nurses can encounter is that of ‘moral complacency’, defined by Unwin (1985: 205) as ‘a general unwillingness to accept that one’s moral opinions may be mistaken’. It could also be described as a general unwillingness to ‘let go’ the primacy of one’s own point of view or to regard one’s own point of view as just one of many to be compared, contrasted and considered. Again, we do not need to look far to find examples of moral complacency in health care contexts.

I recall, several years ago, once being approached by a then gerontology clinical nurse specialist lamenting the ‘short-sightedness’ of some of her students, who were of the view that elderly people in residential care homes should be resuscitated in the event of cardiac arrest, and that the blanket DNR status that was automatically given to all elderly residents upon entering a residential care home was both immoral and illegal. The nurse specialist was insistent that the students were morally wrong, and was clearly disturbed and outraged by their position.

In my response to her, I inquired concerning the discussion she had with her students whether anyone had thought to ask the elderly residents what their preferences were — whether, in the event of cardiac arrest, they wished to be resuscitated or not? It should be noted that, at that time, elderly people entering a residential care agency were invariably asked whether upon their death they wished to be cremated, or where they wished to be buried; they were not always asked, however, whether they wished to be resuscitated in the event of a cardiac arrest. The nurse specialist became obviously agitated by my question, and exclaimed: ‘Surely it is ludicrous to ask all elderly residents whether they wish to be resuscitated!’ After I had expressed my disagreement and pointed out the minimal requirements of the moral principle of autonomy, the nurse specialist retorted: ‘Would you really expect us to ask each and every resident whether they wish to be resuscitated? It’s ludicrous! It’s silly! It’s unnecessary …’. To this retort, I reminded the nurse specialist that elderly residents are already asked whether they wish to be cremated or where they wish to be buried upon their death so what was so difficult about asking them whether they wish to be resuscitated? The nurse specialist was still unconvinced, and persisted in rejecting the view I was putting to her. She further maintained that it was right and proper that all elderly residents should be uniformly designated DNR upon admission to a residential nursing care home. The attitude of the nurse specialist in this anecdote is an example of moral complacency.

Like moral unpreparedness and moral blindness, moral complacency is something which can be rectified by moral education, moral consciousness raising, and reflective practice in an ethical environment. The objective of taking this action would be, of course, to produce in the morally complacent person the attitude that nobody can afford to be complacent in the way they ordinarily view the world — least of all the moral world. This is particularly so in instances where other people’s moral interests are at stake. It is a grave mistake to assume that our moral opinions are ‘right’ just because they are our own opinions. As ethical professionals, our stringent moral responsibility is to question our taken-for-granted assumptions about the world, and not to presume that they are always well founded and unable to be challenged.

A seventh type of moral problem which may be encountered by nurses, and which is similar in many respects to moral complacency, is that of ‘moral fanaticism’. The moral fanatic is someone who is thoroughly ‘wedded to certain ideals’ and uncritically and unreflectingly makes moral judgments according to them (Hare 1981: 170). Richard Hare’s classic case of the fanatical Nazi is a good example here (Hare 1963: Chapter 9). The fanatical Nazi in this case stringently clings to the ideal of a pure Aryan German race and the need to exterminate all Jews as a means of purging the German race of its impurities. The Nazi falls into the category of being a ‘fanatic’ when he/she insists that, if any Nazis discover themselves to be of Jewish descent, then they too should be exterminated along with the rest of the Jews (Hare 1963: 161–2).

Examples of moral fanaticism exist in health care contexts. The surgeon who repeatedly performs ‘futile’ surgery in an attempt to prolong the life of a terminally ill patient, regardless of the dying patient’s wishes to the contrary and the suffering it causes, is an important example here. Morally fanatical doctors in this instance might defend their position by claiming that it is not only medically indicated but strongly warranted from a moral point of view. The maintenance of absolute confidentiality, even though harm might be caused as a result, is another good example. So, too, is the example of a doctor or a nurse forcing unwanted information on a patient in the fanatical belief that all patients must be told the truth — even if the patient in question has specifically requested not to receive the information, and the imposition of the unwanted information on the patient can be shown to be a ‘gratuitous and harmful misinterpretation of the moral foundations for respect for autonomy’ (Pellegrino 1992: 1735).