Theoretical perspectives informing ethical practice

three theoretical frameworks that warrant attention here – namely, those that
involve respectively (and sometimes interdependently) an appeal to:
1 ethical principles ( ethical principlism )
2 moral rights ( moral rights theory )
3 moral virtues ( virtue ethics ).
These three approaches, each informed by the traditions of western moral
philosophy, have emerged as having the most currency and credibility in contemporary
health care contexts. Reasons for this include:
 they have largely emerged from and been refined by practice

 they are able to be readily applied to and in practice

 they are amendable so can be revised and refined in order to be more

responsive to the lived realities of everyday practice.
What are ethical principles?
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 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’. 
As stated earlier, 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 briefly examining the content, prescriptive force and
application of these principles that this discussion now turns.
Autonomy
The term ‘ autonomy ’ comes from the Greek autos (meaning ‘self’)
and nomos (meaning ‘rule’, ‘governance’ or ‘law’). When autonomy is used as a
concept in moral discourse, what is commonly being referred to is a person’s ability to
make or to exercise self-determining choice – literally, to be ‘self-governing’. Included
here is the additional notion of ‘respect for persons’ – that is, of treating or respecting
persons as ends in themselves, as dignified and autonomous choosers, and not as the
mere means (objects or tools) to the ends of others ( Benn 1971 ; Kant 1972 ).
The principle of autonomy, however, is a little different, and is eloquently formulated
by Beauchamp and Walters (1982 : 27) as follows:
 What this basically means is that people should be free to choose and are
entitled to act on their preferences provided their decisions and actions do not stand to
violate, or impinge on, the significant moral interests of others.
Both the concept and the principle of autonomy have important implications for
nursing practice. For example, if autonomy is to be taken seriously by nurses, nursing
practice must truly respect patients as dignified human beings capable of deciding what
is to count as being in their own best interests – even if what they decide is considered
by others (including nurses) to be ‘foolish’. In short, nurses must allow patients to
participate in decision-making concerning their care. Given this, it soon becomes clear
that the whole practice of ‘negotiated patient goals’ and ‘negotiated patient care’ as
advocated by contemporary nursing philosophy has its roots in the moral principle of
autonomy and the derived duty to respect persons as autonomous moral choosers. It is
not derived merely from a concept of ‘acceptable professional nursing practice’.
In application, the principle of autonomy would judge as being morally
objectionable and wrong any act which unjustly prevents autonomous persons from
deciding what is to count as being in their own best interests. The kinds of act which
might come in for criticism here include, for example:
 • 
treating patients without their consent
 • 
treating patients without giving them all the relevant information necessary for
making an informed and intelligent choice
 • 
withholding information from patients when they have expressed a considered
choice to receive it
 • 
imposing information upon patients when they have expressed a considered
choice not to receive it
 • 
forcing nurses to act against their reasoned moral judgments or conscience.
It should be noted, however, that while the moral principle of autonomy is
helpful in guiding ethically just practices in health care contexts it is not entirely
unproblematic. Indeed, its uncritical and culturally inappropriate application in some
contexts may, in fact, inadvertently cause rather than prevent significant moral harms to
patients, for reasons which are considered in Chapter 4 .
Non-maleficence
The term ‘ non-maleficence ’ comes from the Latin-derived maleficent –
from maleficus (meaning ‘wicked’, ‘prone to evil’), from malum (meaning ‘evil’),
and male (meaning ‘ill’). As a moral principle, non-maleficence (literally ‘refuse evil’),
prescribes ‘above all, do no harm’ which entails a stringent obligation not to injure or
harm others. This principle is sometimes equated with the moral principle of
‘beneficence’ (considered below under a separate subheading) which prescribes ‘above
all, do good’. Trying to conflate these two obviously distinct principles under one
principle is, however, misleading. As Beauchamp and Childress (2013 : 151) explain,
not only are these two principles distinct (for instance, our obligation not to kill
someone does seem qualitatively and quantitatively different from our obligation to
rescue someone from a life-threatening situation), but it is important to distinguish
between them so as not to obscure other critical moral distinctions which might be
made in ordinary moral discourse. One instance in which ‘other important distinctions
might need to be made’ is in the case of where both principles might apply to a given
situation, but where the strength of the respective moral imperatives of each may
nevertheless differ significantly and thus might prescribe different courses of action.
‘Stringentness’ thus stands as an important distinction that might be obscured if
the principles of non-maleficence and beneficence were conflated into one single
principle. Beauchamp and Childress (2013 : 151) contend that generally ‘obligations of
non-maleficence are usually more stringent than obligations of beneficence’, and, in
some cases, may even override beneficence particularly in instances where beneficent
acts (e.g. to help others and to provide benefits), paradoxically, are not morally
defensible (e.g. depriving one’s family of food for a week and risking eviction by
failing to pay the rent because of donating the household’s weekly budget to charity).
However, Beauchamp and Childress (2013 : 151) further contend that, while our
obligations not to harm others might be more stringent in some situations than our
obligations to help them, the reverse can also be true (e.g. the justified ‘harm’ of radical
yet lifesaving and ‘beneficial’ surgery).
Applied in nursing contexts, the principle of non-maleficence would provide
justification for condemning any act which unjustly injures a person or causes them to
suffer an otherwise avoidable harm.
Before continuing, some commentary is warranted on the notion of ‘harm’ and
how it might be interpreted (given that it is open to a variety of interpretations). For the
purposes of this discussion, harm may be taken to involve the invasion, violation,
thwarting or ‘setting back’ of a person’s significant welfare interests to the detriment of
that person’s wellbeing ( Beauchamp & Childress 2013 : 153–4; Feinberg 1984 : 34).
Interests, in this instance, are taken to mean ‘a miscellaneous collection, consist[ing] of
all those things in which one has a stake’ together with the ‘harmonious advancement’
of those interests ( Feinberg 1984 : 34). Interests are morally significant since they are
fundamentally linked to human wellbeing; specifically, they stand as a fundamental
requisite (although, granted, not the whole) of human wellbeing ( Feinberg 1984 : 37).
Wellbeing, in turn, can include interests in:
The test for whether a person’s interests and wellbeing have been violated, ‘set
back’, thwarted or invaded rests on ‘whether that interest is in a worse condition than it
would otherwise have been in had the invasion not occurred at all’ ( Feinberg 1984 :
34). For instance, if a person (e.g. a patient) is left psychogenically distressed (e.g. in
emotional pain, anxious, depressed and even suicidal) or in a state of needless physical
pain and / or disability as a result of his / her experiences (e.g. as a patient in a given
health care setting) our reflective commonsense tells us that this person’s interests have
been violated and the person him / herself ‘harmed’. As the American philosopher
Joel Feinberg (1984 : 37) further explains, the violation of a person’s welfare interests
renders that person ‘very seriously harmed indeed’ since ‘their ultimate aspirations are
defeated too’.
Beneficence
The term ‘beneficence’ comes from the Latin beneficus , from bene (meaning
‘well’ or ‘good’) and facere (meaning ‘to do’). The principle of beneficence prescribes
‘above all, do good’; in practice, it entails a positive obligation to literally act for the
benefit of others, viz contribute to the welfare and wellbeing of others ( Beauchamp &
Childress 2013 ). Acts of beneficence can include such virtuous actions as: care,
compassion, empathy, sympathy, altruism, kindness, mercy, love, friendship and
charity. It is recognised, however, that bestowing benefits on others is not always
without cost to the benefactor. Thus there are some limits to the principle; that is, it is
not ‘free standing’ and its application can be appropriately constrained by other moral
(e.g. utilitarian) considerations. To put this another way, we are not obliged to act
beneficently towards others when doing so could result in our own significant moral
interests being seriously harmed or compromised in some way.
Although the notion of ‘obligatory beneficence’ remains a controversial one in
moral philosophy (for instance, it is generally accepted that we are not morally required
to benefit persons on all occasions, even if we are in a position to do so), there are
nevertheless a number of conditions under which a person can indeed be said to have an
obligation of beneficence and that this obligation might, sometimes, be overriding. An
example of such conditions, devised by Beauchamp and Childress (2013 : 207), is as
follows:
The principle and its prescribed obligation of beneficence stands to have an
interesting and useful application in nursing practice. Consider the following
hypothetical case. Mrs Jones, a Jehovah’s Witness, is admitted to an intensive care unit
in the final stages of life, suffering from advanced hepatitis B and severe liver failure.
She has a slow internal haemorrhage and is only semiconscious. Before her alteration in
consciousness she gives her doctors a written statement specifically requesting that she
not be given a blood transfusion under any circumstances. Upon her arrival in the unit,
however, the attending doctor prescribes a unit of blood and requests that it be given
immediately. Mrs Jones’ husband and children are all present and, upon overhearing the
doctor’s request, become very upset. Mr Jones approaches the doctor and asks that his
wife not be given the blood transfusion. He reminds the doctor that Mrs Jones has made
explicit her wish not to have a blood transfusion under any circumstances. Nurse Smith,
the registered nurse caring for Mrs Jones, hears the discussion and is faced with
deciding whether or not to intervene on her patient’s behalf. In making her decision,
Nurse Smith might appeal to the principle of beneficence in the following manner:
 1 
Mrs Jones, a Jehovah’s Witness in the final stages of life, is at risk of suffering a
significant loss (a violation of her spiritual values and beliefs) if she is given the
medically prescribed blood transfusion.
  2 
Action by Nurse Smith, the attending nurse, is needed to prevent Mrs Jones
from experiencing the loss in question.
 3 
Nurse Smith’s action of refusing to administer the prescribed transfusion would
probably prevent Mrs Jones’ loss.
 4 
Nurse Smith’s action will not present a significant risk to her (i.e. she will not
lose her job).
 5 
The benefits gained by Mrs Jones outweigh any harms Nurse Smith is likely to
suffer (given that Nurse Smith autonomously chooses to uphold Mrs Jones’ interests,
and does not stand to suffer any morally significant consequences of her actions).
Weighing up the benefits and burdens, Nurse Smith decides to refuse to give the
transfusion which has been prescribed. The doctor, however, insists that it be given. In
response to this, the nurse points out that the transfusion would probably be of no
clinical benefit to Mrs Jones, as she was clearly in the end stages of her disease – to put
it bluntly, ‘she was dying’. Nurse Smith then suggests to the doctor that perhaps he
would prefer to administer the transfusion himself. The doctor rejects this suggestion,
and the transfusion is not given. Mrs Jones dies a short while later without having to
experience a needless violation of her expressed wishes, values and beliefs.
In summary, by this principle, any act which fails to address an imbalance of
harms over benefits where this can be done without sacrificing a benefactor’s own
significant moral interests warrants judgment as being morally unacceptable.
Justice
The principle of justice (its nature and content), unlike the principles above, is
not so amenable to precise definition or quantification. Questions concerning what
justice is and what its origins are have occupied the minds of philosophers for nearly
3000 years, and to this day remain the subject of philosophical debate ( MacIntyre
1988 ; Nussbaum 2006 ; Powers & Faden 2006 ; Sen 2009 ; Solomon & Murphy
1990 ). Significantly, the end result of this protracted philosophical debate has not been
the development of a singular and refined universal theory of justice, but rather that of a
range of rival theories of justice – both traditional and recent ( Beauchamp & Childress
2013 ; MacIntyre 1988 ). Different conceptions of justice (from the
Latin justus meaning ‘righteous’) have included: justice as revenge (retributive justice –
e.g. ‘an eye for an eye’), justice as mercy (Christian ethics), justice as harmony in the
soul and harmony in the state (Pythagorean ethics, 600 bc –1 ad ), justice as
equity (impartiality and fairness), justice as avoiding parochialism and reducing
(global) injustice , justice as equality (‘equals must be treated equally, and unequals
unequally’), justice as an equal distribution of benefits and burdens (distributive justice
and redistributive justice), justice as what is deserved (‘each according to one’s merit or
worth’), and justice as love ( Beauchamp & Childress 2013 ; MacIntyre 1988 ,
2007; Nozick 2007 ; Nussbaum 2006 ; Outka 1972 ; Powers & Faden 2006 ; Rawls
1971 ; Sen 2009 ; Singer 1991 ; Solomon & Murphy 1990 ; Waithe 1987 ). Over the
past two decades, justice has also been conceptualised as reconciliation and
reparation (restorative justice), a key purpose of which is to ‘restore broken
relationships’ ( Tutu 1999 ; see also Johnstone G 2002 ; Sullivan & Tifft 2006 ).
Arguably one of the most novel conceptions of justice is that of justice as a basic
human need that, like other basic human needs (notably those famously depicted in
Maslow’s hierarchy of human needs), is critical to producing the necessary conditions
of life ( Taylor 2003 , 2006 ).
Given these different conceptions of justice, the problem arises of what, if any,
conception of justice nurses should adopt? While it is beyond the scope of this book to
answer this question in depth, there is nevertheless room to advocate at least three
senses of justice which nurses might find helpful: (1) justice as fairness and impartiality
(equity justice), (2) justice as the equal distribution of benefits and burdens (distributive
and redistributive justice), and (3) justice as reconciliation and reparation (restorative
justice). It is these three senses of justice which will now be considered.
Justice as fairness and impartiality (equity)
Justice as fairness finds interpretation in terms of ‘what is owed or due’
( Beauchamp & Childress 2013 : 250). By this view, it can be said that one acts justly
towards a person when that person has been given what is due or owed; an injustice, in
turn, would involve withholding from that person what is otherwise due or owed.
If a person deserved something, justice is done when that person receives that
particular something. Here, the ‘something’ may be either positive (a reward) or
negative (a punishment). This view relies very heavily on an ‘intuitive’ sense of justice.
For example, we may ‘feel’ it is unjust to punish or censure someone for a harm they
did not cause, or not to punish someone for a harm they did deliberately cause.
Likewise we may feel that it is unjust to reward someone for an accomplishment to
which they contributed nothing, and yet not reward someone who contributed a great
deal.
We do not need to look far in nursing practice to find sobering examples of
where the principle of justice as fairness has been violated. Consider the notable
historical cases where nurses have been subjected to severe legal and professional
censure, held solely responsible and have even lost their jobs because of making an
honest mistake ( Johnstone 1994a ; Johnstone & Kanitsaki 2006b ).
Other examples involve cases where nurses have gained promotion or have
secured employment on the basis of their claiming credit for the work of either their
peers or their subordinates. At the other end of the continuum, some nurses have been
denied promotion or employment because their superior has ignored, or refused for
whatever reasons to recognise significant professional achievements the nurse applicant
has in fact made.
How, then, might we make choices on this view of justice? One possible
approach which has received widespread attention is that discussed by the
contemporary American philosopher John Rawls. He argues, for example, that if parties
are to exercise truly just or fair choices, they must choose from a hypothetically
‘neutral’ position, or from a position of what he describes as being ‘behind the veil of
ignorance’ ( Rawls 1971 : 12). From such a position he argues:
Moral rules
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 prescribes
that persons should be respected as autonomous choosers, capable of judging what is in
their own best interests. As such, people who have the capacity to make autonomous
decisions should be free to act as they wish provided their actions do not violate the
moral interests of others.
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 also 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 is absurd. The relationship between particular moral judgments, moral rules,
moral principles and moral theories is shown in Fig. 3.1 .
 Problems with ethical principles
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:
 • 
deciding correctly which principles apply in a given situation (e.g. ‘Is it the
principle of autonomy or beneficence that applies in this case, or both?’)
 • 
interpreting correctly the imperatives of the principles chosen to guide ethical
decision-making in a given situation (e.g. ‘What does the principle of autonomy require
of me? Is it the case that the principle of autonomy ought always to be upheld?’)
 • 
deciding correctly the relative weights of given principles (e.g. ‘Which principle
has overriding consideration in this case – the principle of autonomy or the principle of
non-maleficence?’)
 • 
balancing the demands of different principles in situations where their
respective though equally weighted demands might conflict (e.g. ‘How can I uphold the
principle of autonomy without, at the same time, violating the principle of justice,
which has an equal bearing in this case?’)
 • 
deciding whether ethical principles apply at all (e.g. ‘This is a matter to be
resolved by kindness and care – by being virtuous – not by appealing to ethical
principles per se.’)
 • 
resolving disagreement with others regarding either of the above (e.g. ‘I feel
strongly that respecting the patient’s autonomy in this case means withholding the
information about his diagnosis as he has requested, but others in the team do not agree
and are going to tell him, insisting he must be told so that he can make informed
choices about his future treatment.’).
 Moral rights
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.
Moral rights based on natural law and divine command
Natural rights theory argues that certain entitlements are simply ‘built into’ the
universe like the laws of gravity, and as such are neither the products of human
invention nor the constructs of other moral theories ( Martin & Nickel 1980 ). A
variation of this thesis is that natural rights have been divinely ordained for all human
beings. From both these points of view, since the laws of nature and the ordinances of
God apply equally to all human beings, it follows that all human beings – young and
old; male, female, transgender and intergendered (e.g. hermaphrodites); homosexual,
heterosexual and bisexual; abled and disabled; black, white and coloured –
unconditionally have natural rights.
Objections to this account of moral rights derive from those raised against a
theological account of morality generally. For example, if it were shown that God did
not exist, or that natural law did not exist, this account of moral rights would
immediately collapse because its very foundation would be pulled out from underneath
it. Another objection rests on the problem that natural rights essentially defy scientific
verification.
Moral rights based on common humanity
Another popular natural rights thesis is that all human beings have rights simply
by virtue of being ‘human’ and ‘equal’. What is critical to this thesis is the notion that
‘being human’ is something over which we have no control; that is, we cannot choose
to be either human or not human ( Martin & Nickel 1980 ). In this sense, then, we can
be said to enjoy a ‘common humanity’. This view of rights is vulnerable to the
objection that not all human rights are moral rights per se. The human right to
education, which is dependent on the availability of educational resources, is an
example of a human right which is not a moral right per se.
Another more serious problem is that, given the recent advancements made in
the field of genetic engineering, ‘being human’ may indeed be something over which
we have control in the near future. Human genes have already been cloned onto animals
(e.g. pigs and fish); it is not far-fetched to imagine that scientists will succeed (if they
have not already done so) in cloning animal genes onto humans. Persons with a genetic
makeup comprising both human and non-human genes could be said to be not ‘fully
human’, at least, not in a ‘speciesist’ sense. Were someone to be not ‘fully human’,
their claim to moral rights on the basis of a common humanity would be cast in doubt.
Conversely, if a non-human nonetheless has human genes and / or human
characteristics (e.g. chimpanzees that are capable of performing abstractions), it too
might hold claim to what are otherwise upheld as being exclusively ‘human rights’ (see
also Dershowitz 2004 : 143).
Moral rights based on rationality
A Kantian thesis of natural rights (i.e. a thesis based on the philosophical views
of the German philosopher Immanuel Kant circa 1724–1804) holds rationality as being
the sole basis upon which a right’s claim can be made. In other words, only those
people who are capable of rational, autonomous thought are entitled to claim moral
rights. One disturbing consequence of this thesis is that any human being (or non-
human being, for that matter) who is unable to reason is not regarded as having moral
status. Such a view clearly excludes infants, brain-dead and intellectually disabled
persons, and others with severe organic brain states corrosive of their ‘personhood’
from having a just claim to moral rights. It might be tempting to dismiss this view as
being merely an intellectual one, of interest only to moral philosophers. There is ample
evidence, however, that this view is influential and has currency in the ‘real world’ of
human affairs. (The most notable examples here can be found in the use of ‘brain-dead’
persons, fetuses and live-born anencephalics as organ donors ( Bioethics Committee,
Canadian Paediatric Society 2005 ; Fost 2004 ; Khan & Lea 2009 ; Meinke
1989 ; Siminoff 2004 ).)
Moral rights based on interests
The North American philosopher Joel Feinberg offers quite a different theory of
moral rights. He argues that, in order for an entity to be able to claim rights
meaningfully, that entity must have interests ( Feinberg 1979 ). To have interests, the
entity must be capable of being either benefited or harmed. In order to be either
benefited or harmed, one must have the capacity to experience pleasure and pain – that
is, have sentience. In short, unless one has sentience one cannot have interests, and thus
cannot be either benefited or harmed, and therefore cannot make claims.
Some have taken this view even further contending that ‘sentience is the
bedrock of ethics’, not just of moral rights ( Balcombe 2016 : 13). This is because it is
fundamentally wrong to ‘deliberately and maliciously cause another pain and suffering’
because pain and suffering are in themselves fundamentally bad ( Balcombe 2016 : 13).
This theory of moral rights can be expressed diagrammatically as shown in Fig. 3.2 .
FIGURE 3.2
Feinberg’s theory of moral rights