SELF
A STUDY
OF THE FOUNDATIONS
DECISION-MAKING
OF ETHICAL
OF NURSES
ABSTRACT. A study of nurses and nursing students was conducted to determine the
various philosophical positions they hold with respect to ethical decision-making in nursing
and their relationship to the subjective-objective controversy in value theory. The study
revealed that most nurses and nursing students tend to be subjectivists in value theory, i.e.,
believe that value judgments are purely personal, private expressions of one's own opinion
or inner-feelings and not believe that value judgments are knowledge claims capable of
being true or false and therefore not expressions of moral requirements and normative
imperatives emanating from an external value structure or moral order in the world. In
addition, the study revealed that most nurses and nursing students are inconsistent in the
philosophical foundations of their ethical decision-making, i.e., in decision-making regarding values they tend to hold beliefs which are incompatible with other beliefs they hold
about values.
Key words: Ethical decision-making, Subjective-objective Distinction, Consistency, Value
Theory, Nursing ethics
INTRODUCTION
The following study is an attempt to identify and understand better the
philosophical positions which nurses and nursing students, knowingly or
unknowingly, utilize in ethical decision-making in health c a r e ) Of special
interest are the various positions in the subjective-objective controversy in
value theory, i.e., whether value judgments are purely personal, private
expressions of one's own opinion and inner-subjective feelings or whether
value judgments are expressions of moral requirements and normative
imperatives emanating f r o m an external value structure or moral order in
the world. This will be elaborated in m o r e detail later.
The increase in interest in ethical decision-making in health care has
been dramatic during the past decade. However, very little empirical data
has been gathered on the issue. Usually those studies that have been
conducted simply report people's opinions on controversial issues such as
abortion, euthanasia, etc. Virtually no studies of actual data gathered on
the theoretical foundations of ethical decision-making have been reported.
This study was undertaken with the objective of identifying the philosophical stances of nurses with respect to ethical decision-making. The study
examines the following hypotheses:
(1) Most nurses tend to be objectivist in value theory, i.e., believe that
value judgments are knowledge claims capable of being true or false and
TheoreticalMedicine 8 (1987) 85--95.
1987 byD. ReidelPublishing Company.
86
DONNIE J. SELF
are expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world.
(2) Most nurses are consistent in the philosophical foundations of their
ethical decision-making regardless of whichever position they tend to hold
on the subjective-objective issue in value theory.
The first hypothesis relates nursing to a fundamental issue in moral
philosophy -- namely, the theoretical status of values. Down through the
centuries value language has been analyzed in many ways. However, the
crucial issue in value theory comes in the subjective-objective controversy
because it is here that the theoretical status of values is determined.
Indeed E. M. Adams notes:
The thesis that value judgments in general and moral judgments in particular have no
objective ground, that they are subjective and private, needs to be thoroughly explored and
assessed. If it is a sound thesis, then we must face up to the consequences. If it is a false
thesis, we must look for ways to regain faith in the objectivity of values. Herein lies the
central task of moral philosophy of our age.2
The second hypothesis relates nursing to one of the most philosophically
desirable characteristics -- namely, consistency. Whatever position one
holds it must be internally consistent in order to be a logically viable
position and ought to be applied consistently to a wide range of circumstances. T h i s hypothesis contends that in decision-making about values
nurses tend to hold beliefs which are basically compatible with other
beliefs they hold about values.
METHOD
The study consisted of gathering, analyzing and interpreting data gathered
from questionnaires submitted to 912 nurses and 195 nursing students at
a major health care center in the United States. This included RNs, LPNs
and student nurses at various stages in their educational program. The
questionnaire consisted of one page containing 9 questions to be answered
affirmatively or negatively and several biographical designations. The
questions were constructed in such a way that there were three questions
relating to each of the three possible positions in the subjective-objective
issue (elaborated below in the Background Information section). The
questionnarie contained no controversial questions such as questions
which would elicit the respondent's feelings about issues of abortion,
euthanasisa, etc. Rather the study was designed to focus on theoretical
foundations of ethical decision-making in health care. However, the
ETHICAL DECISION-MAKING
OF N U R S E S
87
RESULTS
BACKGROUND
INFORMATION
88
D O N N I E J. S E L F
TABLE 1
Nurse Decision-Making Data
Number of
Affirmative
Responses
Percentage
348
92.3%
29
7.7%
158
41.8%
220
58.2%
302
79.9%
76
20.1%
357
94.7%
20
5.3%
164
43.3%
215
56.7%
172
45.6%
205
54.4%
301
79.6%
77
20.4%
180
48.3%
193
51.7%
152
40.5%
223
59.5%
Questions
Number of
Negative
Responses
Percentage
value
e x p e r i e n c e a n d v a l u e l a n g u a g e n e e d s t o b e c l a r i f i e d . V a l u e e x p e r i e n c e is
the affective-conative state that one experiences
or undergoes
when
in
89
E T H I C A L D E C I S I O N - M A K I N G OF NURSES
TABLE 2
Biographical Data
Biographical
Characteristic
Percent of
Respondents
RN
LPN
Student Nurse
Male
Female
Protestant
Catholic
Jewish
Other
41.2
12.3
46.5
2.1
97.9
70.0
16.9
2.4
10.7
TABLE 3
Consistency Comparison
Question Number
Response Required
For Consistency
Actual
Response Received
Yes
No
Majority Actual
Responses
Pair
4
5
yes
yes
or
no
no
357
164
20
215
yes
no
Pair
2
9
yes
yes
or
no
no
158
152
220
233
no
no
Pair
3
7
yes
no
or
no
yes
302
301
76
77
yes
yes
Pair
5
6
yes
no
or
no
yes
164
172
215
205
no
no
Pair
1
8
yes
no
or
no
yes
348
180
29
193
yes
no
90
DONNIE J. SELF
91
tive which exists independently of how one feels about it. Indeed those
persons who are not repulsed by such cruelty are considered sick and in
need of help. The formal ethics of Immanuel Kant and the Judeo-Chrisfian
ethics of the Old and New Testaments are the best known paradigms of
objectivism. Objectivism holds that value judgments are objective in that
they are cognitively significant and make a knowledge claim which can be
confirmed to be true or false. They embody a significant semantic claim.
The content of value judgments is not dependent upon the peculiarities of
the agent but is determinable by any rational observer appraised of the
relevant facts. Pure objectivism maintains that value language is not
reducible to non-value language since value experience discerns a dimension of reality not discernable through any other mode of experience.
Value judgments are not merely expressions of emotions or attempts t o
evoke similar attitudes in others, but rather are of and about an external
value structure or moral order of the world. Values exist independently of
a discerning mind, and there are norms or value requirements regardless
of whether or not anyone is aware of them. Like necessary connections,
value requirements are not dependent upon knowledge of them. Value
language is of and about these value requirements and normative imperatives in reality. Value language is expressive of this value experience, i.e., it
translates into language what is semantically present and felt in value
experience. It relates a dimension of experience which is not expressible
through any other language. Value language is not reducible or translatable into any other language such as factual language. No other kind of
language can express the content expressed in an ordinary value judgment.
The dimension of reality discerned through value experience cannot be
discerned through any other mode of experience.
DISCUSSION
With the above understanding of the subjective-objective distinction in
value theory, the data collected from the questionnaries can be interpreted
more clearly. Analysis of the data requires that hypothesis number i be
rejected and shows that it is not true that most nurses tend to be
objectivist in value theory, i.e., believe that value judgments are knowledge
claims capable of being true or false and are expressions of moral
requirements and normative imperatives emanating from an external value
structure or moral order in the world. This conclusion tends to support
the notion that our culture has become increasingly subjectivistic with respect to values. Since the turn of the century there has been a tremendous
92
D O N N I E J. S E L F
93
rightness of their acts, nurses take many factors into consideration and not
just the usefulness of their act in terms of one pre-eminent factor -- not
even the welfare of the patient solely.
Further, analysis of the data requires that hypothesis number 2 be
rejected and shows that most nurses are inconsistent in the philosophical
foundations of their ethical decision-making regardless of whichever
position they tend to hold on the subjective-objective issue in value theory.
This is to say that nurses simultaneously hold some subjective beliefs and
some objective beliefs about values which are philosophically incompatible with each other. A similar finding in a study of physicians was
reported earlier as referenced in footnote 1. This conclusion was demonstrated by pairing related questions and comparing the actual responses of
the nurses to the responses required for consistency.
Table 3 shows the question pairings, the responses required for consistency, and the actual responses received. In three of the five question
pairs the responses received differed from the theoretically consistent
pattern. For example, with questions 4 and 5, which would require two
affirmative responses or two negative responses for consistency, the actual
response received was a majority of affirmative responses to question 4
and a majority of negative responses to question 5.
Additional evidence from the data which supports the contention
that hypothesis number 2 is false is found in analyzing the responses
to questions number 3 and 7. An affirmative response to both of these
questions simultaneously is contradictory. Yet essentially eight out of
every ten nurses responded affirmatively to question number 3 (79.9%)
and affirmatively to question number 7 (79.6%) at the same time. Perhaps
this is not too surprising since it was noted earlier that the distinction
between values being relative to the person making the judgment versus
being relative to the facts of the circumstances is often not well understood.
Finally inconsistency can also be observed by analyzing the responses
to question number 4 regarding the existence of ethical obligations
independent of knowledge of them -- an essential feature of objectivism.
The large affirmative response to question number 4 (94.7%) requires that
values exist independently of a discerning mind and that there are
normative imperatives or value requirements in reality which reflect the
existence of a normative structure or moral order in the world. But the
existence of such a moral order or of ethical obligations independently of
knowledge of them is philosophically inconsistent with the subjectivist
position noted earlier to be endorsed in various ways by the responses of
the nurses. From all this one can conclude that when the group is viewed
as a whole, nurses are inconsistent in the philosophical foundations of
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D O N N I E J. S E L F
their ethical decision-making. This is not to say that they are any more
or less inconsistent than any other group or profession. But even if
inconsistency in ethical decision-making is universal, it is still undesirable.
CONCLUSION
ETHICAL DECISION-MAKING
OF NURSES
95
NOTES
1 A similar study of physicians and medical students is reported on pages 5 7 - 6 9 of the
February 1983 issue of Theoretical Medicine.
z For the context of this remark see E. M. Adams 11].
3 This brief description of the alternative positions in the subjective-objective distinction
comes from the similar study of physicians and medical students reported on pages
57--69 of the February 1983 issue of Theoretical Medicine.
4 For an extensive elaboration of the positions in the subjective-objective distinction and
the arguments for and against each position see D. J. Self [2, 3, 4, 5].
5 The point of values being relative to the person making the judgment versus values
being relative to the facts of the circumstances is often not well understood. This issue
is addressed in D. J. Self [3].
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