|
"Although the virtues of persistence, patience and commitment lead toward moral clarity, I caution nurses not to be satisfied with certainty. Appreciate, cultivate and welcome the moral uncertainty and ambiguity that you experience along the way." —Mary Ellen Wurzbach |
DOING WHAT'S RIGHT: THE ETHICS OF NURSINGNursing ethics and Hägar the Horrible Many strive for moral clarity, but arriving at that much desired destination guarantees neither truth nor a positive outcome. by Mary Ellen Wurzbach Hägar the Horrible, asked by his son to explain what life is all about, responds: “I guess life is like a long road ... a long, winding, bumpy road with some nice scenic views.” Warming to the opportunity to teach his son how to make good choices, he continues: “When you reach the fork in the road, take the road on the right—the High Road. When you reach the crossroads, go towards Goodness. When the sign says City of Worldliness, you stay on course for City of Your Soul.
One of the primary choices we make in life is choosing to appreciate moral uncertainty, sometimes called moral ambiguity, or choosing to search for moral certainty, sometimes called moral clarity. Often, people positioned to make choices for the rest of us choose moral certainty without seriously considering the moral uncertainty surrounding those choices. Much of my research has been an examination of moral behavior surrounding these two concepts. Moral certainty is defined as absolute belief to which a person is psychologically committed without a doubt. This conviction is based on evidence the person believes to be credible and right. Thus, moral certainty is absolute belief, coupled with what the person regards as irrefutable evidence, leading to willingness to take action. If institutional constraints make action impossible, moral distress may result. To avoid such distress, one nurse included in my research took the following action. “I’ve had a situation,” she told me, “where the doctor ordered an extremely large dose of a narcotic. I drew up the narcotic, gave him the syringe and said, ‘I don’t feel comfortable giving this. I think you should.’ And you know what? He didn’t give it.” Many other nurses who acted with moral certainty indicated that they were trying to avoid moral regret. As one nurse explained: “We had a woman come in complaining of back pain, and I didn’t say too much. Before she was discharged, I didn’t say she was complaining of back pain. We sent the lady home with instructions; she came back within four hours in shock with a ruptured tubal pregnancy. I regretted at that point not pushing the issue of the back pain further. That’s when I made up my mind: If I ever had a suspicion about something, I was going to say it and then deal with the repercussions later, because that lady almost died. If you raise the issue and are ignored, at least you have raised the issue and have no regrets.” Conversely, moral uncertainty arises when one is unsure of what values or principles to apply to a problem. When faced with moral uncertainty, individuals feel loss of control, frustration, anger, depression, stress and anxiety, much of which occurs because the person is faced with lack of knowledge, lack of experience or a unique situation. This all leads to an inability to determine the “right” course of action. One nurse I interviewed described the moral uncertainty she experienced in withholding tube-administered nutrition and hydration in a nursing home. “Even though I know they are in a vegetative state and that they probably aren’t aware of it, I still feel like, well, how do we ... how much do we know they are aware of? Don’t they feel the pain and hunger? I am respecting their wish, but am I really doing what ... am I really ... am I letting them ... you know, am I ... is what I have done making them die an agonizing death?” Because moral uncertainty is so uncomfortable for this nurse, as it is for most people, moral certainty is sought because it seems imperative to the decision-maker. The person wants to “know” what to do. Whether one is morally uncertain (confronted with moral ambiguity) or on a journey seeking moral clarity, I suggest cultivating the following values: persistence, patience and commitment. Calvin Coolidge said: “Nothing can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent” (Coolidge, 1933). Patience is also essential. Patience has not always gotten a good rap. Ambrose Bierce (1993) once described patience as “a minor form of despair, disguised as a virtue.” I still stand by patience as an essential virtue. Finally, commitment is necessary. Augustus William Hare asserted, “Half the failures in life arise from pulling in one’s horse just as he is leaping” (Hare & Hare, 1827). When I speak of commitment, I am talking about taking action based on a cherished value or a conviction. Conviction allows individuals to “stand up” or “speak up” for the things in which they believe. It makes advocacy for a person or a cause possible. It provides a converse argument in situations where possibly only one viewpoint would otherwise be heard. It has many benefits for the person, agency and society. Yet, absolute conviction also has a negative aspect. In my research, the nurses I studied did not tend to question their own beliefs or actions. They did not describe dialogue or discussion of possible alternatives to their chosen action. Because there was little dialogue, mistakes could have been made and unnecessary adversarial feelings created. Moral certainty or clarity can also be positive and admirable. How, then, does one know the difference between a justifiable action based upon reflective moral conviction and an unjustifiable action based upon unfounded zeal or self-deception? Lichtenberg, a philosopher, suggests developing an attitude of detachment from one’s own beliefs in order to see the possibility that one might be “blinded by passions, interests, upbringing, and might be mistaken” (Lichtenberg, 1994). Moral certainty pulls one toward a definite conclusion, a resolution to an uncomfortable situation. It compels one to act. One is driven to follow a particular course of action. Yet, moral certainty does not guarantee a positive or appropriate outcome. It does not guarantee truth, and one may be mistaken. Because experience seems to make moral certainty or clarity more likely, bioethicists convey to decision-makers that sometimes reserving judgment is the more prudent avenue to take, that allowing for the possibility of revising a judgment is the wise decision to make, and that relying totally on moral intuitions based on experience may not be in anyone’s best interests. An aspect of moral certainty is insensitivity to new information. One must cultivate moral sensitivity to other viewpoints and make an effort to hear alternative solutions. As one nurse research participant observed, “Continuous dialogue leads to less moral certainty and also less moral uncertainty.” In philosophy, the word “knowledge” usually implies some degree of certainty. In moral philosophy, moral knowledge is said by some to come from principles. Some say it comes from the virtue or character of the decision-maker. Still others say that contextual variables in the situation and the experience of the person determine the outcome. In my own research, nurses’ experience with an issue and the situation surrounding a decision account for those nurses having the greatest moral conviction. Although the virtues of persistence, patience and commitment lead toward moral clarity, I caution nurses not to be satisfied with certainty. Appreciate, cultivate and welcome the moral uncertainty and ambiguity that you experience along the way. Take the path toward moral clarity, but appreciate the journey. Moral clarity is important, but it is moral uncertainty or ambiguity that raises the ultimate questions. It is from moral uncertainty that consensus arises. It is from uncertainty that a search for knowledge and experience comes. Questioning, investigating and delving deeply into a moral dilemma are essential aspects of moral behavior. As someone once said, “Indecision is the key to flexibility.” We all face ethical dilemmas. Don’t go down the road marked “Moral Clarity” until you have explored the road marked “Moral Ambiguity.” Once on the road to moral clarity, recognize and pay heed to the ambiguities along the way. As Hägar the Horrible said, “Stay on course for the City of Your Soul.” RNL Mary Ellen Wurzbach, RN, MSN, PhD, is a professor in the College of Nursing at the University of Wisconsin-Oshkosh. Comic strip: ©King Features Syndicate
|
“Now
this is where it gets tricky!” says Hägar, as he points
to a bevy of signs that inform passersby they have just entered
Inertia and directs them to destinations beyond that include Moral
Ambiguity, Rationalization, Deep Denial and Self-Delusion. As
if to emphasize that little time is allowed for decision-making,
another sign warns, “No Loitering.”