BY: FR. CHARLES BOUCHARD, OP, STD
When I taught business ethics, I discovered that business people sometimes resisted seeing their choices as "ethical choices." When faced with the prospect of a reduction in force or outsourcing, they would sometimes say, "It's just a business decision."
I had to help them see that there was no value-free zone. Almost every business decision also was an ethical decision, that is, a choice of one good or value over another.
Health care poses the same risk. We can be tempted to say, "It's just a clinical decision." But regardless of how much scientific data or certitude we might have, there still will be value-laden choices that require careful ethical deliberation. Elsewhere in this issue, Roxanne O'Brien makes this point clearly in discussing how a nurse ought to think about the question of collective bargaining. The issue of representation by a third party is one of the most neuralgic in health care, and it goes right to the core of what it means to be a nurse, whose first responsibility is to the patient. How does the nurse weigh the values of having enough influence to assure good work conditions and good pay with the values of professional integrity and responsibility?
There are two big questions in ethics. The first is "What ought I to do?" — not in general, but here and now, in this particular situation. Nurses are faced with dozens of decisions about what to do every day. These discrete choices are the stuff our moral lives are made of.
Ethicists use the fancy term "ethical systems" to describe various ways in which we might answer this question. We could do whatever brings the greatest benefit to the greatest number (utilitarianism). Or we could go by the book, absolving ourselves of individual responsibility by doing whatever the rules or standards of practice say.
We could do what the boss says, although this raises the question of who the boss is. Is the nurse primarily accountable to the physician, the patient, the family, or the hospital administration? This, in itself, can be an ethical dilemma.
Or, we could opt out of any normative approach at all and just say, "Well, I'm going to go with my gut, or my emotions or my intuition and just do whatever feels right." The problem is, it's hard to be part of a moral community or to collaborate with others if our only guiding principle is feelings.
THE IMPORTANCE OF VIRTUE
Ethics is not exhausted or depleted once a dilemma is resolved, however, so there is another big question, namely, "Who ought I to be?" This is an adult question. When we're young, we don't think much about who we are becoming. As we mature, however the "being" question takes on more importance. We begin to think about what all of our individual choices have added up to. This is obviously of primary importance for professionals who must not only do the right thing, but also exhibit moral qualities of trustfulness, dependability, truthfulness, justice, good judgment and compassion. We call these moral qualities virtues.
The importance of virtue — or moral character — is essential to nursing, but I didn't find much evidence of it in online syllabuses I checked. Every nursing school has a course in ethics, but the syllabuses I looked at were often a combination of "ethical and legal issues," which sounds more like compliance than character development. Even the Ethical Code of the American Nursing Association is mostly full of "doing" words (e.g., the nurse "promotes," "advocates," "participates in," "collaborates with"). Only two of the provisions use "being" words (the nurse is "responsible and accountable"). This is not to criticize the code, just to say that, at least from our perspective, it is missing one key component.
Why is virtue so important? First of all, because it is the link between individual choices and our developing moral capacity. Like the skill of athletes or musicians, our moral ability is shaped by many intentional acts. Our moral character is limited when we're young, but it becomes strong and durable and dependable over time. Adult morality is not just knowing about ethics, but having it within us.
Virtue also is important because it reminds us that nursing is "reflective practice." Nursing is not just delivering something to the patient; it is becoming a certain kind of person. We do, we learn, we reflect, we become. Like other professionals, nurses are shaped by their work. They should become better persons as a result of it.
Virtue also is important because, unlike some kinds of rule-based ethics, virtue involves the whole person. Some kinds of ethics say, "Just do it." There isn't much room for feelings or personal satisfaction. To be virtuous is more than just making rational decisions. It means that you have integrated emotions, intuition and relationships into your moral life. How you feel is one important aspect of making a moral choice. The virtuous person takes feelings into account. He knows how he feels about a course of action, but he also knows just how much emotion is enough and when it is time to move from heart to head.
Acquiring virtue is not a solitary pursuit. We can grow in virtue only within a community where friends, colleagues and even patients help us see the truth of ourselves. Virtue is an inherently collaborative undertaking.
Finally, virtues are important because they lead to holiness. Holiness is a word most of us use cautiously, especially when we're talking about ourselves. That's as it should be, because holiness is a serious thing.
Holiness means first of all, wholeness, integrity and authenticity. Second (and contrary to popular belief), holiness is about happiness. We become holy when we are truly happy and fulfilled, when we are doing what we ought to be doing, in the way we ought to be doing it, when our work enables us to live our deepest aspirations.
Finally, holiness means sanctity, or closeness to God. For Christians, this is where grace comes in. Grace is the experienced presence of God. It is "amazing," as the famous hymn goes, because it doesn't make us weird, antisocial or eccentric. In the Catholic view, grace perfects us. It starts with who we are and gradually moves us to the fullness of what God wants us to be. Whatever personality type we are, grace is custom-made. We can be slow and deliberate, task-oriented and results-
oriented, businesslike, compassionate, analytical or artistic. Whatever our gifts may be, grace makes them shine.
Holiness is the link between spirituality and the moral life. Sometimes we think of spirituality and morality as polar opposites: one is warm and fuzzy, the other is prickly and unpleasant. But in the end, both morality and spirituality are about the direction of our lives. In our choices and in our deepest desires, we are either oriented to God and goodness, or we are not.
JUSTICE AND PRUDENCE
There are as many virtues as there are human capabilities. Which are most important for nurses? Let me suggest just two: justice and prudence.
Justice may seem like an odd choice, since it seems to concern mostly obligations and contracts and economics. But justice is really about right relationships. Nurses have to build relationships of trust and cooperation with patients, family and other health care providers. The classic definition of justice is "the will that each receive her due." This definition is beautiful in its simplicity, but it is difficult in application. How much do I give this patient, or to that one? Nurses must have a sense of proportion and of equitable distribution of medical resources, including personal attention. It takes skill and experience to make that calculation well.
Prudence may sound like restraint, but the prudent person is one who knows what to do in a particular situation by applying general rules and knowing why the general rule won't work in this case. Far from restraint, prudence sometimes requires that we do something bold and innovative. This is a kind of judgment that every professional needs, because there are always situations that don't fit the textbook. Prudence enables a nurse to know when to be firm and when to be flexible, when to encourage and when to comfort, when to accede to a patient request and when not to.
So the virtuous nurse is not just a nurse who knows technique or obeys all the rules. Virtuous nurses know themselves. They have internalized the values and skills of their profession in a way that they draw upon them readily, easily and happily.
Perhaps this issue of Health Progress can be an invitation to nurses to reflect upon their own virtue, the ways they have grown in their ability to see reality clearly and make good choices and to find deep happiness in doing it with ease.
FR. CHARLES BOUCHARD, OP, STD, is senior director, theology and ethics, the Catholic Health Association, St. Louis.