The knowledge of ethics and the subsequent theories that have evolved from it is paramount to the profession of nursing. These theories assist nurses with identifying potential problems and developing skills required to determine and justify decisions in given situations. Furthermore, they work to enhance and shape an individual’s ethical beliefs and values. There are a number of ethical theories that have been introduced throughout nursing including the widely agreed upon four; deontology, utilitarianism, virtue ethics and ethics of care.
Of these four, the ethics of care theory is the strongest and most readily relatable to the profession of psychiatry and nursing while the three aforementioned ones are not. This essay is going to explain why the ethics of care theory is the most ready for use in psychiatric nursing practice today and what deontology, utilitarianism, and virtue ethics ultimately lack which would not make their implementation as useful.
Ethics of care is most commonly associated with psychologist Carol Gilligan, who, unlike the developers of the other three major theories, is not a philosopher. (Sobstyl, Week 5/Part 2). Her theory was developed as a response to Lawrence Kohlberg’s moral development theory which females tended to score differently on than males based on the diversity in their approach to situations. (Yeo, Page 58). A distinct moral theory that emphasizes the importance of responsibility, ethics of care is most concerned with the concept of the relationship rather than consequences or rules.
Gilligan stated that girls and women would approach a dilemma in a more contextualized and narrative way whose primary focus was to resolve the details of a problem situation. Males, on the other hand, tend to subscribe to a concept known as “justice of care”. This approach is based on the application of more general abstract principles that do not consider the unique, and at times, differing circumstances that surround a case (Yeo, Page 59). Care ethics view human beings as interdependent entities who value caring relationships and recognize the moral value of emotional feelings.
It focuses on virtues associated with care and views this as being a moral sentiment and response in the context of these relationships. This includes concepts such as compassion, empathy, loyalty, and sympathy. Care ethics encourages altruism in which to create a balance between care of self and care of others and is intended to guide a care-giver’s conduct and provide an ideal with which an individual could use to base a virtuous life on. (Discussion of care, feminist, relational ethics thread, Oct 4th/13).
Care ethics seeks to maintain relationships by putting the well-being of both the care-giver and the care-receiver into context and promoting them within a network of social relations. The theory promotes caring, which is recognized as a skill and not inherent to a particular group of people (Sobstyl, Week 5/Part 2) and interdependence, both which were typically seen as being traditionally female characteristics. Throughout history, ethic theories generally subscribed to the masculine way of thinking wherein the results were viewed as more important than the process.
Because of this, there were doubts that women were as morally developed as men, and trivialized concepts such as attentiveness and compassion in favour of autonomy, reason, and justice. This is where feminine ethics, the concept that has given rise to care ethics, plays a part and has brought to light the dimensions which would otherwise go unnoticed (Yeo, Page 63). By highlighting these that have not been visible in any of the other major theories, it allows for the possibility of alternate theories being formulated and discussed.
This would then provide care-givers a stronger, more concise framework with which to guide ethical decision making. Ethics of care is generally viewed as the antithesis of the deontological and utilitarian theories in that it focuses on the concepts of relationships and interdependence rather than focusing more on the egocentric part of the person and how they are “supposed” to act in a situation. According to Yeo, critics tended to dismiss care ethics as an extension of the virtues theory, however, it contains a number of important differences.
Associated with Immanuel Kant, deontology involves the theory of the “categorical imperative” which illustrates the idea of acting on a rule based on it being reasonable and if others would act on it if in the same situation (Yeo, Page 50). The benefits of this are that it protects the rights of patients and ensures equal treatment while reminding nurses of their accountability as health-care providers. Deontology values the intentions of the individual however is unable to evaluate consequences as they are viewed as occurrences that we have no control over.
It is frequently inappropriate to incorporate into many health-care situations within mental health due to the lack of instances where there is a clearly defined right and wrong answer, or where more than one right answer exists. This theory accounts for absolutes only while failing to consider the gray areas that fall in between. It is difficult to implement deontology into every situation due to the fact that our duty in one instance may not be appropriate for use in another (Deontology discussion thread, Sept 21st/13).
Utilitarianism considers the consequences of a nurses actions and its primary focus is doing the largest amount of good for the greatest number of people. It accounts for the good of society rather than the good of the individual and is viewed as a “consequentialist ethical theory” where consequences must be considered (Sobstyl, Week 4). In doing so, it works to provide behavioural guidance and promote human goodness as a whole. While deontology protects the right of the patient, utilitarianism protects the rights of the greatest number of individuals.
This theory has a place in many nursing settings, however, its most glaring drawback is that it makes it permissible to sacrifice the minority for the “greater good” and can authorize actions generally thought to be immoral (Yeo, Page 54). In a nursing context, according to utilitarianism, a patient, considered the minority, can be given treatment against their will for the benefit of their loved ones who are viewed as the majority in this situation. This is a direct contrast to the standards of care ethics which values compassion as well as sensitivity and concerns for the needs of the patient (Yeo, Page 59).
Virtue ethics focuses on the theory that intentions, decisions and actions of individuals are what make a person “good” or “bad” rather than on rules or principles (Yeo, Page 56). Virtue ethics is not easy to apply to practice as it does not serve to offer enough guidance for nursing action when resolving ethical dilemmas nor is it realistic to determine what kind of person one “should” be as a result of the ambiguity of what an ideal is. It does not make a clear connection between the virtuosity of a person and the quality of care they can provide.
As a person does not have to be inherently good to provide care, it stands to reason that virtue ethics are simply an ideal rather than a must. Furthermore, It is difficult to determine what a virtue is as this can be defined differently depending on an individual’s gender, age, or culture, for example. It is unclear whether virtues are innate or developed through one’s experiences and environment and as a result, provides a very ambiguous framework as to what can be taught and what is based on genetics (Virtue Ethics thread, Oct 8th/13).
Virtue ethics is beneficial, however, in enabling a nurse to stand up for their beliefs based on their virtues and morals. If a care-givers moral ethical value is sound and reflect who they are as a person, their choices can realistically be defended (Virtue Ethics thread, Oct 7th/13). Care ethics identifies clients who are the most vulnerable and provides extra consideration based on the level of their vulnerability to a decision and how strongly they would be affected by this. Unlike with deontology, utilitarianism and virtue ethics, the relationship with others is the starting point in ethics of care.
Less focus is made on the decision maker determining what obligations they have and what is morally just. Instead, focus is placed on how the nurse must respond to these situations (Ethics of care, feminism, relation ethics thread, Oct 4th/13). Ultimately, the measures that nurses take to care for their patients enable the patient to live with as much physical, emotional, social and spiritual well-being as possible. A nurse needs to be attentive to the needs of the client and have a responsibility to be providing holistic care as well as support and education.
Individualized care is a must and needs to be tailored to the unique needs of the patient while considering physical, psychosocial, psychological, spiritual and cultural needs. Lastly, for ethics of care to be effective, the client must be responsive to the care given by the nurse as they are in a vulnerable state and rely on the actions of the care-giver. While ethics of care does value the relationships that exist in nursing and places importance on the holistic approach that a nurse provides through maintaining a therapeutic nurse-client relationship, like all theories, it too has its drawbacks.
Frederick Nietzche expressed in his writings that subservient traits were being favoured due to the perceived oppression that women faced as a result of the male dominated theories that existed before it (Discussions of care, feminist, relational ethics thread, Oct 4th/13). It can also lead to gender bias where females are favoured in the caring roles rather then males who are typically viewed as being in the “justice role” where the end result is most valued (Yeo, Page 60). It is important to remember that ethics of care is not gender-specific and can certainly be applied to males as it does females.
The same can be said for females who gravitate more towards the ethics of justice way of thinking. Another criticism of this theory is that is can be viewed as an extension of the virtue theory wherein the concept of compassion, caring and interdependence are viewed as virtues rather than an independent ethical theory capable of standing on its own. In the fight to place value on “feminine traits”, it is important not to devalue these traditionally “masculine traits” in order to not alienate those who do not share similar viewpoints.
Ethic theories are not meant to provide a rulebook that a nurse can follow as law, but rather identifies guidelines which a nurse may use to enhance and guide their practice. By taking concepts from these theories, a nurse can further develop their practice by building trust with their patients, determining consequences, self-reflecting, determining how to react in a given situation and how to remain professional in situations where this may be difficult.
Ethics of care provides the best overall framework with which to guide nurse’s actions within a health-care context. Dealing with vulnerable patient populations, it is vital that a relationship be in place, be therapeutic as well as proactive, and work towards realistic goals that can be made and continued outside of a hospital setting. Hildegard Peplau was instrumental in establishing the concept of the nurse-patient relationship, and it stands to reason that this is still largely considered the foundation of nursing today.
With a solid foundation of trust it then becomes easier to establish therapeutic relationships and therefore provide more well-rounded holistic care. Implementing this theory will reduce the large number of readmissions that occur in many hospitals because the therapeutic nurse-patient relationship establishes clear boundaries, determines appropriate nursing behaviours as identified throughout the care ethics theory, and considers the importance of goal-setting (Discussion of care, feminine, relational ethics thread, Oct 8th/13) .
Deontology, utilitarianism and virtue ethics fail to take into account the big picture which is the concept of relationships and how important they are in being able to formulate strategies and progress with treatment. Relationships promote trust, reduce fears, and provide a sense that one is not alone and that there is support available for them. In conclusion, the ethics of care theory remains the strongest when applied to a mental health setting after taking into account the benefits and limitations of the deontology, utilitarianism and virtue ethics theories.
Despite the debate that continues in health-care settings regarding which theory is the strongest, the fact remains that ethics of care directly addresses the relationship aspect of nursing and views it as being vital in providing treatment. It identifies that clients suffering from mental health illnesses are vulnerable and continue to be stigmatized within our culture while the aforementioned three fail to clearly make this distinction