Choosing a Leadership Style (Marquis & Huston, 2012)
DISPLAY 4.1 Leadership Roles and Management Functions Associated With Ethics
Leadership Roles
1. Is self-aware regarding own values and basic beliefs about the rights, duties, and goals of human beings 2. Accepts that some ambiguity and uncertainty must be a part of all ethical decision making
3. Accepts that negative outcomes occur in ethical decision making despite high-quality problem solving and decision making
4. Demonstrates risk taking in ethical decision making
5. Role models ethical decision making, which is congruent with the American Nurses Association (ANA) Code of Ethics and Interpretive Statements and professional standards
6. Clearly communicates expected ethical standards of behavior
7. Role models behavior that eliminates theory–practice–ethics gaps and promotes ethical behavior as the norm
Management Functions
1. Uses a systematic approach to problem solving and decision making when faced with management problems with ethical ramifications
2. Identifies outcomes in ethical decision making that should always be sought or avoided 3. Uses established ethical frameworks to clarify values and beliefs
4. Applies principles of ethical reasoning to define what beliefs or values form the basis for decision making
5. Is aware of legal precedents that may guide ethical decision making and is accountable for possible liabilities should they go against the legal precedent
6. Continually reevaluates the quality of personal ethical decision making based on the process of decision making or problem solving used
7. Constantly assesses levels of moral uncertainty, moral distress, and moral outrage in subordinates and intervenes as necessary to protect quality patient care and worker well-being
8. Recognizes and rewards ethical conduct of subordinates
9. Takes appropriate action when subordinates demonstrate unethical conduct
Moral Issues Faced by Nurses
There are many terms used to describe moral issues faced by nurses, including moral indifference, moral uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas. Moral indifference occurs when an individual questions why morality in practice is even necessary. Moral uncertainty or moral conflict occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is.
On the other hand, moral distress occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action. Thus, morally distressed nurses often
demonstrate biological, emotional, and moral stress as a result of this intrapersonal conflict (Edmonson, 2015). Indeed, morally distressed nurses often experience anger, loneliness, depression, guilt, powerlessness, anxiety, and even emotional withdrawal. This then leads to turnover as the morally distressed nurse leaves the stressful situation for a less stressful environment (Edmonson, 2015). Barlem and Ramos (2015) suggest that moral distress is one of the main ethical problems affecting nurses in all health systems and thus is a threat to nurses’ integrity and to the very essence of quality of patient care.
Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it. For example, in a high-profile whistleblower case in New Mexico, six nurses at Memorial Medical Center in Las Cruces independently voiced concerns to their nurse-managers over a 6-year period regarding inadequate and inappropriate care being given by an osteopathic physician on staff (Minority Nurse Staff, 2015). In addition, the nurses brought the alleged shortcomings of this particular doctor to the attention of other physicians. The doctor in this case was later accused of negligence and incompetence after one of her patients died from sepsis and another suffered a serious injury.
But for reasons that are still unclear, the hospital allegedly failed to act on the nurses’ complaints. Instead, the hospital challenged the nurses’ actions and disciplined them, citing state regulations that forbid sharing patient information for any reason. The hospital also was alleged to have retaliated after the case was filed and the nurses agreed to testify against the doctor.
Lastly, the most difficult of all moral issues is termed a moral or ethical dilemma, which may be described as being forced to choose between two or more undesirable alternatives. For example, a nurse might
experience a moral or ethical dilemma if he or she was required to provide care or treatments which were in conflict with his or her own religious beliefs. In this case, the nurse would likely experience an intrapersonal moral conflict about whether his or her values, needs, and wants can or should supersede those of the patient.
Because ethical dilemmas are so difficult to resolve, many of the learning exercises in this chapter are devoted to addressing this type of moral issue.
Individual values, beliefs, and personal philosophy play a major role in the moral or ethical
decision making that is part of the daily routine of all managers.
How do managers decide what is right and what is wrong? What does the manager do if no right or wrong answer exists? What if all solutions generated seem to be wrong? Remember that the way managers approach and solve ethical issues is influenced by their values and basic beliefs about the rights, duties, and goals of all human beings. Self-awareness, then, is a vital leadership role in ethical decision making, just as it is in so many other aspects of management.
No rules, guidelines, or theories exist that cover all aspects of the ethical problems that managers face.
However, it is the manager’s responsibility to understand the ethical problem-solving process, to be familiar with ethical frameworks and principles, and to know ethical professional codes and standards. It is these tools that will assist managers in effective problem solving and prevent ethical failure within their organization.
Critical thinking occurs when managers are able to engage in an orderly process of ethical problem solving to determine the rightness or wrongness of different courses of action.
Ethical Frameworks for Decision Making
Ethical frameworks guide individuals in solving ethical dilemmas. These frameworks do not solve the ethical problem but assist the manager in clarifying personal values and beliefs. Four of the most commonly used ethical frameworks are utilitarianism, duty-based reasoning, rights-based reasoning, and intuitionism (Table 4.1).
Ethical frameworks do not solve ethical problems but do assist decision makers in clarifying personal values and beliefs.
The teleological theory of ethics is also called utilitarianism or consequentialist theory. Using an ethical framework of utilitarianism encourages decision making based on what provides the greatest good for the greatest number of people. In doing so, the needs and wants of the individual are diminished. Utilitarianism also suggests that the end can justify the means. For example, a manager using a utilitarian approach might decide to use travel budget money to send many staff to local workshops rather than to fund one or two people to attend a national conference. Another example would be an insurance program that meets the needs of many but refuses coverage for expensive organ transplants. As illustrated in Learning Exercise 4.6, the organization uses utilitarianism to justify lying to employee applicants because their hiring would result in good for many employees by keeping several units in the hospital open.
Deontological ethical theory judges whether the action is right or wrong regardless of the consequences and is based on the philosophy of Emanuel Kant in the 18th century. Primarily, this theory uses both duty-based reasoning and rights-based reasoning as the basis for its philosophy. Duty-based reasoning is an ethical framework stating that some decisions must be made because there is a duty to do something or to refrain from doing something. In Learning Exercise 4.5, the supervisor feels a duty to hire the most qualified person for the job, even if the personal cost is high.
Rights-based reasoning is based on the belief that some things are a person’s just due (i.e., each individual has basic claims, or entitlements, with which there should be no interference). Rights are different from needs, wants, or desires. The supervisor in Learning Exercise 4.5 believes that both applicants have the right to fair and impartial consideration of their application. In Learning Exercise 4.6, Sam believes that all people have
the right to truth and, in fact, that he has the duty to be truthful.
The intuitionist framework allows the decision maker to review each ethical problem or issue on a case-by- case basis, comparing the relative weights of goals, duties, and rights. This weighting is determined primarily by intuition—what the decision maker believes is right for that particular situation. Recently, some ethical theorists have begun questioning the appropriateness of intuitionism as an ethical decision-making framework because of the potential for subjectivity and bias. All of the cases solved in this chapter involve some degree of decision making by intuition.
Other more recent theories of ethical philosophy include ethical relativism and ethical universalism. Ethical relativism suggests that individuals make decisions based only on what seems right or reasonable according to their value system or culture. Conversely, universalism holds that ethical principles are universal and constant and that ethical decision making should not vary as a result of individual circumstances or cultural
differences.
Principles of Ethical Reasoning
Both teleological and deontological theorists have developed a group of moral principles that are used for ethical reasoning. These principles of ethical reasoning further explore and define what beliefs or values form the basis for decision making. Respect for people is the most basic and universal ethical principle. The major ethical principles stemming from this basic principle are discussed in Display 4.2.