Chapter Three

ETHICAL THEORIES

DEONTOLOGY
Deontology is a theory that suggests actions are good or bad according to a clear
set of rules. Its name comes from the Greek word deon, meaning duty. Actions that
obey these rules are ethical, while actions that do not, are not. This ethical theory is
most closely associated with German philosopher, Immanuel Kant. His work on
personhood is an example of deontology in practice. Kant believed the ability to use
reason was what defined a person.
From an ethical perspective, personhood creates a range of rights and
obligations because every person has inherent dignity – something that is fundamental
to and is held in equal measure by each and every person. This dignity creates an
ethical ‘line in the sand’ that prevents us from acting in certain ways either toward other
people or toward ourselves (because we have dignity as well). Most importantly, Kant
argues that we may never treat a person merely as a means to an end (never just as a
‘resource’).
Kant’s ethics isn’t the only example of deontology. Any system involving a clear
set of rules is a form of deontology, which is why some people call it a “rule-based
ethic”. The Ten Commandments is an example, as is the Universal Declaration of
Human Rights. Most deontologists say there are two different kinds of ethical duties,
perfect duties and imperfect duties. A perfect duty is inflexible. “Do not kill innocent
people” is an example of a perfect duty. You can’t obey it a little bit – either you kill
innocent people or you don’t. There’s no middle-ground. Imperfect duties do allow for
some middle ground. “Learn about the world around you” is an imperfect duty because
we can all spend different amounts of time on education and each be fulfilling our
obligation. How much we commit to imperfect duties is up to us.
Our reason for doing the right thing (which Kant called a maxim) is also
important. We should do our duty for no other reason than because it’s the right thing to
do. Obeying the rules for self-interest, because it will lead to better consequences or
even because it makes us happy is not, for deontologists, an ethical reason for acting.
We should be motivated by our respect for the moral law itself. Deontologists require us
to follow universal rules we give to ourselves. These rules must be in accordance with
reason – in particular, they must be logically consistent and not give rise to
contradictions.
 The appeal of deontology lies in its consistency. By applying ethical duties to all
people in all situations the theory is readily applied to most practical situations. By
focusing on a person’s intentions, it also places ethics entirely within our control – we
can’t always control or predict the outcomes of our actions, but we are in complete
control of our intentions. Others criticize deontology for being inflexible – by ignoring
what is at stake in terms of consequences, some say it misses a serious element of
ethical decision-making. De-emphasizing consequences has other implications too –
can it make us guilty of ‘crimes of omission’? Kant, for example, argued it would be
unethical to lie about the location of our friend, even to a person trying to murder them!
For many, this seems intuitively false. One way of resolving this problem is through an
idea called threshold deontology, which argues we should always obey the rules unless
in an emergency situation, at which point we should revert to a consequentialist
approach.

TELEOLOGY
Teleology comes from the Greek word telos which means end, aim or goal and
logos which means explanation, reason or finality. In contrast to the deontological
approach, the teleology ethical orientation emphasizes outcomes over the process. It is
a results-oriented approach that defines ethical behavior by good or bad consequences.
Ethical decisions are those that create the greatest good. Teleology provides a moral
basis for the professional ethics of medicine, as physicians are generally concerned
with outcomes and must therefore know the telos of a given treatment paradigm.

1. Consequentialism
Consequentialist ethics come from the teleological branch of ethical theory. You
will remember that teleological theories focus on the goal of the ethical action.
Consequentialist theories are those that base moral judgements on the outcomes of a
decision or an action. If the outcomes of an action are considered to be positive, or to
give rise to benefits, then that action is held to be morally right. On the other hand, if the
outcome causes harm, then the action is held to be morally wrong. The judgement of
right or wrong depends on the consequences of the decision or action.
Consequentialism is a theory that suggests an action is good or bad depending on its
outcome. An action that brings about more benefit than harm is good, and of course, an
action that causes more harm than benefit is not.
 Consequentialism is an attractive ethical approach because it provides clear and
practical guidance – at least in situations where outcomes are easy to predict. The
theory is also impartial. By asking us to maximize benefit for the largest number of
people, we set aside our personal biases and self-interest to benefit others. One
problem with the theory is that it can be hard to measure different benefits to decide
which one is morally preferable. Is it better to give my money to charity or spend it
studying medicine so I can save lives? Consequentialism can struggle to compare
different moral values. The other concern people express is the tendency of
consequentialism to use ‘ends justify the means’ logic. If all we are concerned with is
getting good outcomes, this can seem to justify harming some people in order to benefit
others. Is it ethical to allow some people to suffer so more people can live well?

2. Egoism
Egoism is the theory that one's self is, or should be, the motivation for all of our
actions. It is worth distinguishing between egoism as a descriptive argument (an
argument that tells us how the world actually is) and egoism as a normative argument
(an argument that tells us how the world ought to be).
Egoism as a descriptive argument describes human nature as self-centred. In its
strongest form, it argues that individuals only act in their own self-interest. Even where
they appear to be acting in others' interests, descriptive egoism explains that the person
is really motivated by their own self-interest disguised by arguments (rationalizations) of
'doing one's duty' or 'helping others'. In fact, our motivation behind doing 'good deeds'
may be to make ourselves feel good, to make ourselves look good in the eyes of others,
or because we believe that, by helping others, others will help us. Even if we donate
money to charity anonymously, we may still only really do this because it makes us feel
good about ourselves. In contrast, egoism as a normative argument tells us that we
should be acting in our own interests, as this is the only way that overall welfare can be
improved. If everyone acts in their own self-interest, then society will become more
efficient, which will be in everyone's interest. It is therefore morally right to pursue one's
own self-interest.
The New Catholic Encyclopedia states that egoism "incorporates in itself certain
basic truths: it is natural for man to love himself – he should moreover do so, since each
one is ultimately responsible for himself." The moral censure of self-interest is a
common subject of critique in egoist philosophy, with such judgments being examined
as means of control and the result of power relations.
3. Utilitarianism
The modern form of the consequentialist theory of utilitarianism derives from 19th
century British philosophers such as Jeremy Bentham and John Stuart Mill, and it has
been particularly influential in areas of the world influenced by British culture. Rather
than maximize individual welfare, utilitarianism focuses on collective welfare and it
identifies goodness with the greatest amount of good for the greatest number of people:
the 'greatest happiness principle'. So, maximizing benefits for the greatest number of
people involves net assessments of benefit: utility is the net result of benefits and
'disbenefits' -or costs. Utility has entered modern economics as a key quantitative
concept. The concept of trade-offs is specifically embraced and social and
environmental cost-benefit analyses are explicit utilitarian tools for assessing the
goodness of an action. A simple balance sheet of costs and benefits can be drawn up to
assess the overall utility of a decision. Utilitarianism has three essential elements:
 Whether an action is right or wrong is determined solely by its consequences.
 The value of the consequences of an action is assessed in terms of the amount
of happiness or well-being caused.
 In assessing the total happiness caused to a number of people, equal amounts
of happiness are to have equal value, no one person's happiness having
greater value that another's.

4. Virtue Ethics
Virtue ethics are normative ethical theories which emphasize virtues of mind,
character, and sense of honesty. Virtue ethicists discuss the nature and definition of
virtues and other related problems that focus on the consequences of action. These
include how virtues are acquired, how they are applied in various real-life contexts, and
whether they are rooted in a universal human nature or in a plurality of cultures.
A right act is the action a virtuous person would do in the same circumstances.
Virtue ethics is person rather than action based: it looks at the virtue or moral character
of the person carrying out an action, rather than at ethical duties and rules, or the
consequences of particular actions. Virtue ethics not only deals with the rightness or
wrongness of individual actions, it provides guidance as to the sort of characteristics
and behaviors a good person will seek to achieve. In that way, virtue ethics is
concerned with the whole of a person's life, rather than particular episodes or actions. A
good person is someone who lives virtuously - who possesses and lives the virtues.
 Virtue Ethics is a useful theory since human beings are often more interested in
assessing the character of another person than they are in assessing the goodness or
badness of a particular action. This suggests that the way to build a good society is to
help its members to be good people, rather than to use laws and punishments to
prevent or deter bad actions. For virtue theory to be really useful it needs to suggest
only a minimum set of characteristics that a person needs to possess in order to be
regarded as virtuous. Being virtuous is more than having a particular habit of acting like
generosity but it means having a fundamental set of related virtues that enable a person
to live and act morally well. Most virtue theorists would also insist that the virtuous
person is one who acts in a virtuous way as the result of rational thought (rather than,
say, instinct).

Principles
Virtue ethics teaches:
 An action is only right if it is an action that a virtuous person would carry out in
the same circumstances.
 A virtuous person is a person who acts virtuously
 A person acts virtuously if they "possess and live the virtues"
 A virtue is a moral characteristic that a person needs to live well

Lists of Virtues
Most virtue theorists say that there is a common set of virtues that all human
beings would benefit from, rather than different sets for different sorts of people, and
that these virtues are natural to mature human beings - even if they are hard to acquire.
This poses a problem since lists of virtues from different times in history and different
societies show significant differences. The traditional list of cardinal virtues includes:
Prudence, Justice, Fortitude / Bravery and Temperance.

Good Points of Virtue Ethics

It centers ethics on the person and what it means to be human. It includes the
whole of a person's life.

Bad Points of Virtue Ethics

It doesn't provide clear guidance on what to do in moral dilemmas although it
does provide general guidance on how to be a good person. Presumably a totally
virtuous person would know what to do and we could consider them a suitable role
model to guide us. There is no general agreement on what the virtues are and it may be
that any list of virtues will be relative to the culture in which it is being drawn up.
VIRTUE ETHICS AND NURSING
Virtue ethics is an approach that focuses on character with the assumption that a
person of good character will tend to behave in ways that are consistent with their
character. A virtue ethics for nursing is therefore concerned with the character of
individual nurses and seeks ways to enable nurses to develop character traits
appropriate for actions that enhance wellbeing. This chapter offers some insights into
the nature of virtue ethics from an Aristotelian perspective and includes an outline
of the virtue of phronesis (practical wisdom) which provides guidance in situations
where it is not obvious what action would be the virtuous action. Virtue ethics is
contrasted with modern ethical theory (deontology and utilitarianism) and some ways in
which virtue ethics can enhance professional nursing practice are considered. A good
character is a cornerstone of a good nursing.

CORE VALUES OF A PROFESSIONAL NURSE

Professional values are the guiding beliefs and principles that influence your
work behavior. Your professional values are usually an extension of your personal
values such as honesty, generosity and helpfulness. These values may change over
time and around different life events, your core beliefs should stay the same. Nurses
professional values are acquired during socialization into nursing from codes of ethics,
nursing experiences, teachers, and peers.
Professional nursing values were defined as important professional nursing
principles of human dignity, integrity, altruism, and justice that serve as a framework for
standards, professional practice, and evaluation. Schank and Weis stated that these are
“standards for action that are accepted by the practitioner and/or professional group and
provide a framework for evaluating beliefs and attitudes that influence behavior”. The
American Association of Colleges of Nursing (AACN, 1998) identified five values
essential for the professional nurse: altruism, autonomy, human dignity, integrity and
social justice.

Values Professional Behavior

  Understands cultures, beliefs, and
Altruism: Nurse’s concern for the welfare perspectives of others.
of patients, other nurses, and other health  Advocates for patients.
care providers.  Take risks on behalf of patients and
colleagues.
 Mentors other professionals.
Values Professional Behavior
 Plans care in partnership with patients.
Autonomy: Nurses respects patient’s right  Honors the rights of patients and
to make decisions about their health care. families to make decisions.
 Provides information so patients can
make informed choices.
 Provides culturally competent and
Human dignity: Nurses values and
sensitive care.
respects the inherent worth and  Protects patient’s privacy.
uniqueness of all patients and colleagues.  Designs care with s sensitivity to
individual patient needs.
 Provides honest information to
patients and the public.
Integrity: Nurses acts honestly and  Document care honestly and
provides care based on an ethical accurately.
framework.  Seeks to remedy errors made by self
or others.
 Demonstrates accountability of own
actions.
Social justice: Nurse upholds moral, legal,  Supports fairness and nondiscrimina-
and humanistic principles by ensuring tion in the delivery of care.
equal treatment under the law and equal  Promotes universal access to health
access to quality health care care.

The other values every nurse should work to are known as the 'six Cs'. The six Cs
are care, compassion, competence, communication, courage, and commitment.