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Module 1
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Introduction
Let’s start by asking an important question: What is ethics? Watch the video below to be introduced to the world of ethics.
Before diving into the content of this module, let’s have a look at some key concepts:
EthicsEthics is a critical and systematic reflection on human behavior (attitudes and actions) in the light of human dignity.MoralityMorality is defined as the set of accepted and tradition-stable norms of behavior of a group or society. Morality is what 'one' does. While ethics requires critical reflection and argumentative foundation, morality refers to the actual lived behavioral consensus.DeontologyAn overview of the responsibilities and duties of healthcare professionals, as they are described in the codes of ethics.Take another lesson of Module 1So why is ethics important in nursing practice and why are codes of ethics necessary? Watch the video below to find out!
The ICN Code of Ethics for Nurses
Time to have a closer look to a code of ethics for nurses, to get an idea of what is included in the provisions. Visit the website of the International Council of Nurses (ICN) you can find more information on The ICN Code of Ethics for Nurses.
Click here to download The ICN Code of Ethics for Nurses.
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Lesson 1: Ethical approaches
Before we go into a substantive description of ethics, we will briefly consider the different ways in which ethical problems can be approached. We make a distinction between a normative, a descriptive and a meta-ethical method.
Descriptive ethics
Descriptive ethics reports on the values and norms of a particular group or community. One limits oneself to the phenomena as they actually occur. However, in addition to describing them, an attempt is also made to explain them. For example, descriptive ethics can describe the values and standards that are advocated in nursing education and practice to describe the ethically competent nurse. Empirical ethics is a good example of descriptive ethics. In empirical ethics, one tries to describe and explain ethically sensitive practices using empirical methods. For example, what are nurses' attitudes towards euthanasia and what factors influence these attitudes?
Normative ethics
In normative ethics one wonders what an ethically responsible action is. Ethical criteria are sought to assess human actions. These criteria provide a certain image of the ethical good. They are founded on a coherent set of ethical principles. This approach is therefore characterized more by a rational (argumentative) than a descriptive way of thinking. In our opinion, normative ethics is the heart of ethics. It is the framework within which the indications for ethical behavior are formulated and substantiated. Normative ethics is classified in three theories: deontology, consequentialism and virtue ethics. To learn more about normative ethics watch the introductory video on the right.
Meta ethics
Finally, metaethics can be defined as the systematic reflection on the functioning of ethics as a science, on its arsenal of concepts and its methods. This mainly concerns the critical assessment of basic ethical principles and the method of argumentation, based on questions such as: what are actually values and norms; can these be proven to be correct and/or universally valid; are they of a personal or general nature; what is the precise relationship between ethical principles, norms, values and virtues; how is moral judgment made and what conditions must it meet?
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Lesson 2: Ethical standard of human behavior
In normative ethics, one reflects on the ethical quality of human actions. This reflection is embedded in a certain image of humanity. The way in which people are interpreted is the ultimate starting point for an ethical assessment. In connection with a concept of a human being, a certain criterion is chosen from which to analyze and judge human actions. This criterion will function as a kind of ethical benchmark against which actions are measured. In the development of ethics, determining the precise content of this standard is an indispensable element. After all, this introduces a certain generally applicable instrument into ethics.
- We describe the ethical criterion with the term human dignity. By this we do not mean a concrete reality, but a permanent task. It is about a continuous pursuit of a more human society. The criterion for determining whether our actions are ethically responsible is the extent to which we look for the most humane solution in concrete situations. The question that must undoubtedly concern us now is what exactly we mean by human dignity. It is not simply possible to formulate an unambiguous answer to this. Click the tab "The Case of Jef and Hilda" to see an example from the care of older adults.
In a psychogeriatric center, Jef and Hilda, two older adults with dementia, live in the same living group. Jef is a widower and has two children, who rarely gets visit. Hilda, on the other hand, has never been married, but has led a very active life as a social nurse. Jef and Hilda regularly talk to each other during the day. This usually results in touching and caressing each other. Their expressions of tenderness confuse other residents and causes unrest in the department. More and more residents are starting to touch and hug each other. Some nurses experience this behavior as annoying and discuss the problem with the management. The management decides to place Jef and Hilda in two different living groups. Now that Jef and Hilda no longer meet in the living group, they visit each other during occupational therapy. The therapist, Marc, has noticed that Jef has been regularly contacting Hilda lately. He thinks this is wonderful. However, he is told by the management that Jef and Hilda will no longer may have contact, because their cuddling behavior does not correspond with the management's vision on decent relationships and sexuality. (Inspired by Ebskamp and Kroon, 1994)-
- Should Marc simply implement the management's decision? He believes that older adults with dementia have just as much right to physical tenderness as others.
- Are the interests of Jef and Hilda served by this decision?
- What does human dignity mean in the field of sexuality among the older adults?
- Is banning and suppressing expressions of tenderness and love among the older adults humane?
- Is setting up a separate cuddling area an acceptable alternative?
It is not easy to make choices in concrete circumstances that move towards a concept of human dignity shared by everyone. This does not alter the fact that we do have a certain insight into the basic features of human dignity. The human sciences help us to describe, among other things, the physical, psychological, relational, social and philosophical components of being human and human well-being. For example, thanks to psycho-geriatrics, we are gaining increasingly better insight into the importance and place of affective relationships and the experience of sexuality in the lives of older adults with dementia. These insights are gradually translated into the design of care processes (including architecture, spiritual guidance, relaxation). Therefore, it is essential that ethics remains open to new insights from various sciences. We must continually look for what, within the possibilities we currently have, improves the quality of human life. New emphasis can therefore always be placed on the concept of 'human dignity'. This also means that we must be fully ethically creative in every situation.
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Lesson 3: Values and Norms
Take another lesson of Module 1Having defined ethics as thinking about human behaviour from the perspective of human dignity, let’s learn more about the role of values and norms in ethics. Watch the following video.
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Lesson 4: Conscience
Take another lesson of Module 1We learnt about the role of values and norms in ethics. But what is the role of conscience in the context of providing ethical care? Watch the following video and find out!
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Lesson 5: The task of ethics
The ethicist will generally not prescribe to others how or what to decide. After all, we assume that every person 'practices ethics', insofar as he thinks about the question of whether certain views and realities are good or not. Every person has a form of intuitive ethical feeling that makes him receptive to reality and makes him experience it as good or bad. An example of this is the spontaneous reaction of people to the effects of medical technology. The reaction can be positive (technology as progress, the subjugation of a hostile nature, expression of creativity, service to humanity) or neutral (technology as value-free, objective) or even negative (technology as something artificial, as threatening, as alienating). This spontaneous ethical appreciation must be further clarified and examined if it is to develop into a genuine ethical reflection.
Ethical reflection does not make intuitive ethical sensing redundant. On the contrary, an ethicist that wants to be authentic and credible must start from the lived experiences of people who live up to their responsibility. The ethicist can act suggestively for the individual and provide important criteria that he must take into account for his judgment of conscience, but he cannot replace his judgments of conscience. It is the specific task of the ethicist to critically analyze people's intuitive ethical sense and to clarify the underlying views, feelings and assumptions, without sidelining the responsibility of those involved. In this way he transcends arbitrariness and brings broader support to ethical analysis. The key is to remove the personal emotional veil that often covers ethical problems; then rationally locate the values and norms at play; and finally, placing them in a logical context in order to propose ethically sound decisions. In this way, ethics can be reformulated as a systematic guide to making choices. Ethics then has more of an illuminating and constructive task and less of a normative and accusatory tone
Take another lesson of Module 1 -
Lesson 6: Principlism, care ethics, vulnerability, care, and dignity
Medical ethics has grown spectacularly over the past fourty years. Almost all areas of medical intervention – from the very beginning of human life to the end of life – have gradually become the subject of ethical reflection. While medical-ethical discussions were initially conducted privately, mainly by doctors and ethicists, over the years they have increasingly been opened up and evolved into social debates in which politicians and even the entire population participate directly or indirectly. We will now be introduced to the ethical theory to which medical ethics owes this success, and then we will consider the downside of this success. We will present the care-ethical framework and we will explain the difference between individual and relational autonomy.
Principles-oriented autonomy approach
The success and social impact of medical ethics go hand in hand with a number of ethical models that have made ethics a manageable and accessible reflection exercise. An ethical method that can also be used as a useful guideline by non-ethicists such as doctors and nurses. The most popular ethical model that has undeniably contributed to the growth and flourishing of medical ethics is the so-called principle approach. This model first appeared in 1979 thanks to the groundbreaking book 'Principles of Biomedical Ethics' by the American philosophers Tom Beauchamp and James Childress (Beauchamp & Childress, 2020).
To learn more about the basic bioethical principles included in this book, watch the video.
Conflict of principles
Within the principle approach, every ethical problem that arises within clinical practice is understood as a conflict of rights and obligations. These rights and obligations can be expressed at a theoretical level using four conflicting principles: the principles of respect for autonomy, nonmaleficence, beneficence, and the principle of justice. For example, you can understand euthanasia as a conflict between the modern principle of respect for the patient's autonomy on the one hand and the ancient Hippocratic principle of 'doing no harm' (nonmaleficence) on the other. Or again: the patient's autonomous will to die conflicts with the doctor's duty not to cause harm and therefore not to end life. In the following case we clearly see these conflicting interests.
Caroline, a 43-year-old Belgian woman, presented herself to the psychiatry consultation at a university hospital. She was now seen by the psychiatrist for the third time, in the context of her request for euthanasia. Caroline led a very active life. As a civil engineer, she was one of the founders of important developments in the field of telemedicine. For a few years now, she had retired from professional activities and delved into some paranormal sciences (reiki, mindfulness, etc.). She followed numerous training courses in various countries and also wrote several books. She had a 14-year-old son whom she raised alone since her husband died seven years ago. She had a new partner for four years, who would continue to care for her son when she was no longer there. Caroline's euthanasia request is not based on terminal physical suffering, but on unbearable psychological suffering. She is done, says she has had a wonderful life and has achieved everything she wanted to achieve. She has been suffering from depression for a few years now, sometimes with deep depressions, and has made a serious suicide attempt. She expresses her euthanasia request in a calm, friendly, but decisive manner. It is quite difficult for the psychiatrist to empathize with the suffering of Caroline, who appears to him as a powerful woman. But she has been repeating the euthanasia wish for several months, and she substantiates her wish clearly and rationally: she is satisfied with her life, has gotten everything she can, but now it is gone, there is nothing left to live for. The psychiatrist decides to carry out the euthanasia, taking into account all due care measures contained in Belgian euthanasia legislation
Watch the video to understand how the principle approach applies to Caroline’s case:
This simplifying view of the principle approach results in a number of essential components of healthcare practice being overlooked. What, for example, about human attitudes such as care and empathy? Or what about the quality of the care process and the way in which everyone interacts with each other in that process? Let us pause here to consider some essential aspects of moral reality that are overlooked by the principles approach. Watch the video:
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Lesson 7: Care-oriented relational aproach
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The ethical scope of healthcare has been expanded enormously in recent years. While in the early years of medical ethics only the strictly medical domain provoked ethical interest, the entire health care field has now become the subject of ethical reflection. Not only ethical attention for the exclusive field of work of doctors, but also for, for example, nursing care, chronic care, and healthcare policy both within healthcare institutions and at a societal level. This domain expansion has led to ethical reflection within healthcare being increasingly referred to as 'healthcare ethics' instead of 'medical ethics'.
This broadening of views has also exposed some limitations of the principles approach in ethics, not least the problematic nature of the great emphasis placed on the principle of respect for individual autonomy.
Autonomous expressions of will from competent patients can usually be respected since these patients can participate in the entire ethical decision-making process themselves. And that is why the principles approach is usually used: to resolve ethical problems involving competent persons. These problems manifest themselves, for example, in the field of genetics, reproductive medicine, organ donation and prelevation, and the end of life of competent persons. But the growing ethical interest in chronic care, elderly care, and mental health care is increasingly bringing the perspective of the incapacitated patient into ethical discussions. It is in these domains that the autonomy-based principle approach struggles to provide ready-made solutions. Because how can one respect the autonomy of a patient if he or she is no longer competent or perhaps never has been?
According to the care-oriented relational approach, ethical reflection on care practices should not start from the ideal of the autonomous and rational agent, but from the relational context in which care practices are embedded. By providing care, caregivers enter as persons into a relationship with a vulnerable fellow human being who needs care. However, it is not clear from the beginning what answer can be considered as the more adequate and appropriate answer to the care needs of a particular person. Finding the right answer is not the result of a general and abstract balancing of principles or of logical deduction. It is reached through a shared dialogical process of communication, interpretation, and understanding that takes place within the care relationship.
In a care-oriented relational approach, care is the central concept. To find out more about the concept of care and its link with ethics watch the following interview with Prof. Joan Tronto discussing what care is and how it relates to every aspect of our lives.
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Watch Denise's case below and then the 3 following videos to learn how to apply the care orientedrelational approach.
1. The relational embeddedness of ethical problems
2. Clinical-ethhical decision-making as an interpretive process
3. The institutional dimension of care
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We have seen how the care approach applies to clinical-ethical decision-making. Let’s now learn more about the foundational ethical framework that drives the care-oriented approach. Read the article under "Recomending Reading" tab and learn more about the foundations of dignity-enhancing nursing care and the key concepts that should guide an ethical approach to nursing. These concepts outline the ethical essence of nursing care.
In a dignity-enhancing care approach it is important to listen to the lived experiences of all those involved. In the following video you can hear from caregivers and care receivers, talking about choice and control.
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- Gastmans, C. (2013). Dignity-enhancing nursing care: A foundational ethical framework. Nursing Ethics, 20(2), 142–149. (subscription required).
https://doi.org/10.1177/0969733012473772
- Gastmans, C. (2013). Dignity-enhancing nursing care: A foundational ethical framework. Nursing Ethics, 20(2), 142–149. (subscription required).
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Lesson 8: Individual and relational autonomy
We already saw the important role that respect for autonomy plays in ethical discussions in healthcare. However, within the care ethics approach the dominant image of the autonomous person who stands completely independently of himself has been challenged by the idea of relational autonomy which is based on the connectedness of people with each other. In the following video, Carlos Gómez-Vírseda Martínez explains the concept of relational autonomy in relation to individual autonomy.
Carlos Gómez-Vírseda (Madrid, 1985) is a medical doctor with clinical experience as head of the Internal Medicine Service at the Good Samaritan Hospital in N’Djamena - Chad (2013-2015). He is also a Jesuit priest, with studies in Philosophy at the Pontifical University of Salamanca (2008-2010) and in Theology at the Pontifical University of Comillas (2015-2018). He obtained a Research Master in Theology and Religious Studies at the KU Leuven (2018-2020). He participated in the Pastoral Care Service at the Clinique Saint-Jean (Brussels), with a particular engagement in the palliative care and oncology services.
As an ethicist, his research focuses on the concept of relational autonomy in end-of-life care ethics. As a medical doctor, he carries out various projects on community health and social determinants of health in low-income countries. He is currently initiating a PhD study on the topic of conscientious objection in Euthanasia and Assisted Suicide.
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- Gómez-Vírseda, C., de Maeseneer, Y., & Gastmans, C. (2019). Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Medical Ethics, 20(1). (open access)
https://doi.org/10.1186/s12910-019-0417-3
- Gómez-Vírseda, C., de Maeseneer, Y., & Gastmans, C. (2019). Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Medical Ethics, 20(1). (open access)
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Synopsis
In this module we were introduced to ethical aspects of nursing practice and the basic concepts that are important for ethical reflection. We gained insight into ethical terminology and ethical methodology, as a prerequisite for a sound analysis of ethical questions in nursing practice. We also learnt how to use 'human dignity' as an ethical criterion in the ethical evaluation of human behavior and explored the contribution of ethics to thinking about good care.
Take another lesson of Module 1