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The moral metaphors of nursing.

The essence of metaphor is understanding and experiencing one thing in terms of another. Metaphorical concepts structure and reflect what we perceive, how we act, and how we relate to other people. In nursing ethics, several metaphors have emerged which have had a great impact on nursing practice. These metaphors include the military metaphor which exemplified nursing during the 1800s, the advocacy and academic metaphors which became a philosophical basis for nursing during the 1960s, and the individualist and community as caring metaphors which have emerged more recently. Although beneficial in some ways, these metaphors may be obscuring the complex moral reality of nursing practice. This article defines a moral metaphor, critiques nursing's moral metaphors, and provides an historical overview of their development with examples of how they have and do affect nursing practice.

Ethics, Nursing↗

Clinical nursing supervision in the workplace--effects on moral stress and job satisfaction.

AIM: To investigate nurses' satisfaction with their work environment and moral stress levels as effects of systematic clinical nursing supervision. BACKGROUND: Nurses have identified high workload, low influence over work assignment, limited avenues for skills development and diminishing support from supervisors as sources of considerable tension resulting in deterioration of work conditions and decreased job satisfaction. METHODS: This study is a descriptive-correlational study. Data were analysed by means of descriptive statistics. RESULTS: The major result indicates moral stress in the workplace. It was found that a significant relationship existed between moral sensitivity and systematic nursing clinical supervision. CONCLUSION: The results point to the need to support nurses in developing personal qualities, integrated knowledge and self-awareness, which is in line with the effects of clinical nursing supervision reported in other studies.

Adult↗

Dialogue and decision in a moral context.

One of the most widely accepted tenets in postmetaphysical normative ethics is the principle of dialogue as a foundational authority. Conceptually, the dialogical model is valuable, in that it allows a binding yet mutable underpinning of moral discourse. However, dialogue has its limits. The main drawback lies in the fact that deliberations can be very lengthy, perhaps even infinite. In other words, deliberation does not always lend itself to action. From the vantage point of applied ethics, in this case, bioethics and forensic ethics, this is not a minor shortcoming since these disciplines are concerned with situations involving some sort of urgency. Aporia is not an option in most cases. It is thus pressing to consider the moment of decision inherent to moral judgement and action that puts an end to dialogue. From the realm of abstract norm justification, one must move on to the contextualist discourse of application. To be rational, however, decision must avoid authoritativeness or any type of arbitrariness. What, then, could serve as a reasonable criteria for the rational application of norms? What aspects should be envisaged for a sound reflective decision? This paper will attempt to sketch some answers that could contribute to the question of the necessary contextual application of accepted norms by paying heed to, systemizing and sometimes finding fault in the arguments given by judges who had to settle cases touching sensitive moral issues.

Decision Making↗

Supporting the moral development of medical students.

Philosophers who studied moral development have found that individuals normally progress rapidly in early adulthood from a conventional stage in which they base behavior on the norms and values of those around them to a more principled stage where they identify and attempt to live by personal moral values. Available data suggest that many medical students, who should be in this transition, show little change in their moral development. Possibly, this relates to perceived pressures to conform to the informal culture of the medical wards. Many students experience considerable internal dissidence as they struggle to accommodate personal values related to empathy, care, and compassion to their clinical training. Educational interventions that positively influence this process have established regular opportunities for critical reflection by the students in small groups. Other interventions include faculty development to enhance role modeling and feedback by clinical faculty. The author espouses more widespread adoption of these educational interventions.

Education, Medical↗

The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions.

The moral authority for professional ethics in medicine customarily rests in some source 'external' to medicine, i.e., a pre-existing philosophical system of ethics or some form of social construction, like consensus or dialogue. Rather, 'internal' morality is grounded in the phenomena of medicine, i.e., in the nature of the clinical encounter between physician and patient. From this, a philosophy of medicine is derived which gives moral force to the duties, virtues and obligations of physicians qua physicians. Similarly, an ethic specific to the other healing professions, law, teaching or ministry, can be derived from the specific ends to telos of each of these professions, which like medicine, are focused on a special type of human relationship.

Attitude of Health Personnel↗

Reconstructionist Confucianism and health care: an Asian moral account of health care resource allocation.

In this article, I offer an abridged reconstruction of the foundational elements of Confucian moral commitments, which, I will argue, still provide the background moral substance for moral reflection in mainland China, Hong Kong, Taiwan, Singapore, and Korea. The essay presents implications of Confucianism for establishing an appropriate health care system and critically assesses the features of current health polices in mainland China, Hong Kong, and Singapore. The goal is to offer a family-oriented, non-individualist account of resource allocation that takes family authority and responsibility seriously.

Bioethics↗

Moral panic versus the risk society: the implications of the changing sites of social anxiety.

This paper compares moral panic with the potential political catastrophes of a risk society. The aim of the comparison is threefold: 1. to establish the position of risk society threats alongside more conventional moral panics; 2. to examine the conceptual shifts that accompany the new types of threats; and 3. to outline the changing research agenda. The paper suggests that as new sites of social anxiety have emerged around environmental, nuclear, chemical and medical threats, the questions motivating moral panic research have lost much of their utility. Conceptually, it examines how the roulette dynamics of the risk society accidents expose hidden institutional violations that redound into 'hot potatoes' that are passed among and fumbled by various actors. Changing conceptions of folk devils, claims making activities, and of a safety are also discussed.

Crime↗

The effects of locus control and field independence-dependence on moral reasoning.

This study investigated whether stages of moral reasoning vary as a function of locus of control and degree of field independence. Results, based upon 36 female undergraduates, indicated a tendency for both variables to provide some prediction of morality status when used conjointly. This derived from the fact that field independent-internal Ss has disproportionately higher scores on Kohlberg's Moral Judgment Interview than field dependent-internal, field independent-external, and field dependent-external Ss. The latter showed no appreciable differences among them.

Cognition↗

Moral reasoning of Piagetian-matched retarded and nonretarded children and adolescents.

The moral reasoning of four IQ/etiology groups was investigated: 19 organically abnormal moderately retarded, 19 organically abnormal mildly retarded, 19 mildly retarded due to psychosocial disadvantage, and 19 nonretarded individuals. In each group 12 Ss were preoperational and seven concrete operational. Moral reasoning was assessed by an instrument using moral dilemmas based on Kohlberg's procedures. The Slosson Intelligence Test was used to determine the IQs and mental ages of each S. Piagetian stage was determined with the standard conservation of number tasks. The findings indicated no overall significant differences between the mildly retarded and the nonretarded Ss or between the mildly retarded and the moderately retarded Ss, but differences were found between the moderately retarded and the nonretarded Ss. A significant interaction was found between the two independent variables, IQ/etiology and cognitive level. The results were discussed as supporting Zigler's development position and as damaging to Kohlberg's position.

Adolescent↗

Children's evaluations of morality in the context of peer, teacher-child, and familial relations.

The purpose of this study was to investigate how children evaluate moral transgressions (rule violations that do not involve conflicts) and conflicts (stories involving peer, teacher-child, and familial relations) and how children weigh different issues and re-evaluate their decisions after hearing new information about the conflict. Results showed that children at all ages supported decisions by authorities (peer and adult) to ignore social order violations to prevent harm or a failure to share. Decisions to give preference to interpersonal relations were made for issues about harm but not about sharing resources. The findings demonstrate that children give priority to the prevention of harm and a failure to share for some, but not all types of moral conflicts, and that the salience of moral consequences influences their overall evaluation.

Attitude↗

Moral judgment maturity of process and reactive schizophrenics.

Premorbid adjustment, paranoid symptomatology, and role orientation were examined as major predictors of moral judgment maturity in 40 male schizophrenics. In addition, control predictors included age, intelligence (block design and vocabulary), length of hospitalization, length of illness, social position (education and occupation), and severity of illness. A multiple regression equation of premorbid adjustment, block design and vocabulary combined, and education was the best predictor of moral judgment maturity. These results suggest the importance of cognitive and social skills in the development of moral judgment maturity in schizophrenics.

Adult↗

Moral treatment in asylums and general hospitals in 19th-century America.

Moral treatment, a therapeutic approach that emphasized character and spiritual development, and called for kindness on the part of all who came in contact with the patient, flourished in American mental hospitals during the first half of the 19th century. Many of its essential features also existed then in the treatment of physical illness in American general hospitals. Changing social and welfare services and advances in scientific medicine contributed to a subsequent decline in moral treatment and to a divergence between the therapeutic approaches of the two kinds of hospitals. In recent years, there has been a gradual convergence in their treatment modes. Contemporary social and welfare services are contrasted with traditional moral treatment.

Deinstitutionalization↗

Purity and passion: risk and morality in Latina immigrants' and physicians' beliefs about cervical cancer.

This paper examines how physicians' beliefs about risk factors for cervical cancer compare with Mexican and Salvadoran immigrant women's views (hereafter Latina immigrants). Between August 15, 1991 and August 15, 1992, we conducted ethnographic interviews with 39 Mexican immigrant women, 28 Salvadoran immigrant women, and 30 physicians in northern Orange County, California. Physicians and Latina immigrants converge on their beliefs that sexual behavior is a predominant risk factor for cervical cancer. They diverge, however, on their reasons. Latina immigrants' perceptions of health risks are embedded in a larger set of cultural values centering around gender relations, sexuality, and morality. Latina immigrants also emphasized men's behavior as risk factors. Physicians' views, on the other hand, are largely based on the epidemiology of cervical cancer risk factors. They emphasized beginning sexual relations at an early age, multiple sexual partners, and infection with sexually transmitted viruses. Some physicians, however, displayed moral interpretations of the sex-based risk factors for cervical cancer through the use of the culturally-loaded term "promiscuous" in place of "multiple sexual partners," through specific references to morality, and through characterizations of women at risk for cervical cancer. Both the physicians and the Latina immigrants in our study paid considerably less attention to socioeconomic factors. Our results have important implications for physicians who provide health care for Latina immigrants. Physicians should be clear to point out that women need not be "promiscuous" to get cervical cancer.

Adult↗

Moral issues in sport: the child's perspective.

Sport offers opportunities for children to identify and resolve moral issues. Moral issues in sport have primarily been studied from the researcher's perspective, with the child's perspective relatively ignored. Thus, the purpose of this study was to explore the nature and content of the issues children experienced in sport. Interview participants consisted of 7 boys and 8 girls ranging in age from 10 to 12 years (M = 11.6 years, SD = 1.7) who had competitive youth sport experience. An inductive content analysis revealed that children identified issues surrounding three overall dimensions concerning fairness of adult's actions, negative game behaviors, and negative team behaviors. Specific examples of issues included unfair actions by coaches, disrespecting opponents, and selfish behavior in practice. The self-identified issues both confirmed and expanded upon the content found in hypothetical moral dilemmas in sport.

Child↗

Domains of deontic reasoning: resolving the discrepancy between the cognitive and moral reasoning literatures.

Deontic reasoning has been studied in two subfields of psychology: the cognitive and moral reasoning literatures. These literatures have drawn different conclusions about the nature of deontic reasoning. The consensus within the cognitive reasoning literature is that deontic reasoning is a unitary phenomenon, whereas the consensus within the moral reasoning literature is that there are different subdomains of deontic reasoning. We present evidence from a series of experiments employing the methods of both literatures suggesting that people make a systematic distinction between two types of deontic rule: social contracts and precautions. The results call into question the prevailing opinion in the cognitive reasoning literature and provide further support for both an evolutionary view of deontic reasoning and the more domain-specific perspective found in the moral reasoning literature.

Adolescent↗

Euthanasia and physicians' moral duties.

Opponents of euthanasia sometimes argue that it is incompatible with the purpose of medicine, since physicians have an unconditional duty never to intentionally cause death. But it is not clear how such a duty could ever actually be unconditional, if due consideration is given to the moral weight of countervailing duties equally fundamental to medicine. Whether physicians' moral duties are understood as correlative with patients' moral rights or construed noncorrelatively, a doctor's obligation to abstain from intentional killing cannot be more than a defeasible duty.

Ethical Theory↗

Inactivating a total artificial heart: special moral problems.

It seems generally correct that patients (or their valid surrogates) should be able to withdraw consent for the use of the total artificial heart (TAH) just as they presently may withdraw consent for other life-prolonging technologies such as the ventilator, but lingering moral problems remain with such decisions. First, should patients be permitted to demand actual removal of the TAH rather than mere deactivation? Second, foregoing other life-prolonging technologies is normally considered "indirect" killing and is therefore judged legal (as well as moral to those who accept only indirect killing). As long as the society includes irreversible stoppage of the heart as one of the criteria for death, however, stopping a TAH will be considered direct killing, i.e., murder. To circumvent this inconsistency, society must change its conclusion that stopping other life-prolonging technologies is merely indirect killing, explicitly legalize direct killing by means of stopping a TAH, or revisit the definition of death to eliminate the cardiac standard for death from the definition of death. Assuming that the stopping of the TAH with patient or surrogate consent is acceptable, we must then face the question of whether physicians who believe the TAH is serving no purpose can unilaterally stop the device against the wishes of a patient or surrogate who believes it is still serving a worthwhile purpose. Clinicians should be presumed authoritative in determining the predicted effect of the TAH, but, if the TAH can temporarily prolong life for a patient in a way that is desired by the patient or surrogate, case law, professional society recommendation, and moral analysis all support the conclusion that the TAH must be continued even against the conscientious objection of the physician

Advance Directives↗

Moral dilemma: to kill or allow to die?

The thesis of this paper is that while allowing a person to die with care can be morally justified in particular cases, the option of mercy killing can never be morally defended. There is a significant moral difference between these two concepts. Furthermore, the wedge argument, the medical fallibility argument, and the medical care and trust argument provide cogent and convincing reasons for maintaining a legal distinction between mercy killing and letting a person die.

Double Effect Principle↗