The old view of nurse as handmaiden did not credit them with having to make moral decisions. If we examine the actual practice of professional nurses 100 years ago, we would probably find they were indeed always faced with moral issues. The wish and ability to be a moral agent is implied, if not a requisite, for contemporary nurses. Today nurses practice in very complex situations, both in the care they deliver and in the social structures in which they work. Responsibility and accountability require nurses to make moral decisions at many junctures.
The Cambridge dictionary defines agency as the ability to take action or to choose what action to take. Morality refers to conduct, character, and motivation based on internalized social values acquired from life experiences. Our values, those principles and behaviors that are important to us, determine our definition of what is good or bad, right or wrong. Identifying and examining our values is key to understanding why we behave as we do and how we make moral decisions. Moral agency then, is having the intent and then acting to pursue, achieve, and maintain optimal beneficial outcomes consistent with the moral/ethical principles of one’s practice. The Canadian Code of Ethics for Nurses defines a moral agent as “someone who has the capacity to direct their actions to some ethical end, for example good outcomes for patients” (cited in Fortier & Malloy, 2019).
Exercising moral agency involves recognition of a moral issue, making a moral choice, and taking moral action. “Every nursing act that intervenes in the life of a patient has at least the possibility of enhancing or transgressing some value cherished by that person.” Moral uncertainty occurs if the nurse is not sure whether something is a moral issue. Moral dilemmas occur when there is more than one equally valid moral choice to make. Moral distress is a feeling created by constraints to moral agency, leaving the moral agent feeling powerless or conflicted.
The terms moral and ethical are often used interchangeably. Ethics is a philosophic discipline for examining moral behavior and for prescribing a method for moral decision making. The 2015 ANA Code of Ethics for Nurses serves as a guide for “ethical analysis and decision-making” based in “moral tradition.” It expresses the “values, virtues, and obligations” on which nursing practice is based. Nurses are expected to adhere to the values, moral norms and ideals of the profession (ANA, 2015).
Two traditional schools of moral theory are deontological and teleological. Deontological theory is based on the four principles of autonomy, beneficence, non-maleficence, and fairness/justice (Matzo & Sherman, 2010). Decisions are made assuming the right and ability of individuals to make decisions for themselves, rather than being passive and accepting whatever outcome. Principles should be applied in all similar situations to achieve fairness. Teleological theory considers the consequences of “right” action, achieving the greatest benefit for the greatest number of people. The intent of the moral agent and adherence to norms is less important than overall benefit. (Matzo & Sherman, 2010).
The Ethics of Care adds the network of an individual’s relationships to the decision-making process. Human beings are interdependent, and thus vulnerable. Care relationships go beyond deontological principles and thus should include compassion and greater contextual considerations in decision making. (DePanfilis et al., 2019). Ethical decisions aim to maintain and enhance these relationships, developing trust, protecting individuality, and taking responsibility. It includes truth telling, being able to listen and be with a patient’s suffering. Care should be delivered in a humane and dignified manner. A patient’s values, goals, and wishes are established through dialogue and communication. Relationships should have boundaries, but not be devoid of emotion.
Grace cites James Rest, a psychologist, as having four cognitive processes to help build “ethical competence.” 1) Ethical sensitivity helps in evaluating the presence of a moral issue. 2) Moral reasoning draws on professional and life experience to arrive at possible moral actions. 3) Motivation moves individuals to decide which action is best in a given context, and 4) Moral character enables planning action that would overcome obstacles to a positive outcome (Grace, 2018).
Ethical competence is needed for moral agency, but much more is required. The practitioner needs self-awareness and courage to be able to execute effectively. The feeling labeled “moral distress” arises from feeling ethically competent but thwarted by circumstance from being able to ACT on one’s moral principles. Students and new nurses may feel too unfamiliar or inexperienced to voice concerns and strongly advocate. Bureaucracies and organizational cultures are hard to change. Staffing and supply shortages may wear down a nurse’s reserve. To develop and maintain agency one will need ongoing education, support, self-care, and resilience.
Questions and exercises to consider with classmates and/or colleagues:
Code of Ethics for Nurses with Interpretive Statements, 2015 American Nurses Association
Code of Ethics for Registered Nurses (2017 edition) Canadian Nurses Association
DePanfilis, L., DeLeo, S., Peruselli, C., Ghirotto, L. & Tanzi, S. (2019). “I go into crisis when…” ethics of care and moral dilemmas in palliative care. BMC Palliative Care, 18:70.
Fortier, E. & Malloy, D. (2019). Moral agency, bureaucracy and nurses: a qualitative study. Canadian Journal of Practical Philosophy, Vol 3, 2019.
Grace, P. (2018). Enhancing nurse moral agency: the leadership promise of Doctor of Nursing Practice preparation. OJIN: The Online Journal of Issues in Nursing, 23(1).
Liaschenko, J. & Peter, E. (2016). Fostering nurses’ moral agency and moral identity: The importance of moral community. Hastings Center Report, 46(5): S18-S21.
Matzo, M. & Sherman, D. W. (2010). Palliative Care Nursing, 3rd ed. New York, NY: Springer Publishing Company.
Raines, D.A. (1994). Moral agency in nursing. Nursing Forum, 29(1), 5-11.
Ronnegard, D. (2015). The fallacy of corporate moral agency. Issues in Business Ethics, 44, 9-15. DOI: 10.1007/978-94-017-9756-6_2.
Traudt, T., Liaschenko, J., & Peden-McAlpine, C. (2016). Moral agency, moral imagination, and moral community: Antidotes to moral distress. The Journal of Clinical Ethics, 27(3), 201-13.