Health care is replete with ethical questions, and the field of bioethics continues to expand as new discoveries are made (Beauchamp & Childress, 2001). Community health nurses face an expanding number of ethical dilemmas every day.
Imagine, for example, that you are providing health care to a population of migrant farm workers whose housing lacks adequate toilets, bathing facilities, heating, and equipment for cooking and refrigerating food. You recognize that this is a valid health and safety issue. However, when you report the situation to your supervisor, you are told to ignore the conditions because the wineries that employ the workers contribute heavily to a high-profile clinic for all low-income children in your area. What would you do?
What if you were working in a homeless shelter and were told to evict someone who would not agree to take a tuberculin skin test. You agree that residents should comply with this demand, but would you hesitate to implement the eviction if the resident were elderly or the teenage mother of a newborn?
Within the United States, many marginalized people are failed by the public health care system or go without any health care at all. At the same time, affluent individuals enjoy a plethora of health care options, including preventive screenings and health promotion classes. Community health nurses often are confronted by this disparity when making ethical decisions about client care.
In addition to these dilemmas within U.S. borders, progress in the United States often is linked to the exploitation of people in less-developed countries, and this contributes to widening disparities in health, wealth, and human rights.
Failure to respond to such global challenges only leads to greater poverty and deprivation, continuing conflict, escalating migration, and the spread of infectious disease, all further adding to our ethical dilemmas.
Advances in technology also contribute to ethical dilemmas. For example, electronic health records make client information readily accessible, thus raising issues of confidentiality, clients’ rights, and informed consent (Ries &
Moysa, 2005). Technology also forces nurses to confront the issues of genetic testing and stem cell research, as well as assisted suicide and euthanasia (Buroughs, 2005; Yoshimura, 2006; Hurst & Mauron, 2006). Further ethical questions arise regarding organ, tissue, and limb transplants and the decisions about who is to receive them (Delmonico, 2006).
Underlying every issue and influencing every ethical and professional decision are values. Ethics and values are inex- tricably intertwined in professional decision-making, because values are the criteria by which decisions are made.
Values
What are values? A value is something that is perceived as desirable or a personally held abstract belief “about the truth and worth of thoughts, objects, or behavior” (Guido, 2006, p. 2). A value motivates people to behave in certain ways that are personally or socially preferable. Values are usually derived from societal norms, as well as from family and/or religious beliefs. We develop our value system as a result of our experiences with others (e.g., family, peers, schools,
churches, jobs). As seen in Chapter 5, a group’s culture often is defined by its members’ common or shared values.
Standards for Behavior
In general, values function as standards that guide actions and behavior in daily situations or act as a code of conduct for living one’s life. Once internalized by an individual, a value, such as honesty, becomes a criterion for that individ- ual’s personal conduct. Values may function as criteria for developing and maintaining attitudes toward objects and situations or for justifying a person’s own actions and atti- tudes. Values also may be the standard by which people pass moral judgments on themselves and others.
Values have a long-term function in giving expression to human needs. Values motivate people in their work set- ting, in their personal lives, and in dealing with their health, as well as with the larger society. In addition, values are used as standards to guide presentation of the self to others, to ascertain personal morality and competency, and to per- suade and influence others by indicating which beliefs, atti- tudes, and actions of others are worth trying to reinforce or change. As a practitioner, values act as a compass to direct the nurse when working with clients.
Qualities of Values
The nature of values can be described according to five qual- ities: endurance, hierarchical arrangement, prescriptive-pro- scriptive belief, reference, and preference.
Endurance
Values remain relatively stable over time, persisting to provide continuity to personal and social existence. Enduring reli- gious beliefs, for example, offer stability to many people.
This is not to say that values are completely stable over time;
values do change throughout a person’s life. Certainly, the values of children are different from adults. Moral develop- ment generally follows a prescribed path, according to Lawrence Kohlberg (Colby & Kohlberg, 1987) and Carol Gilligan (1982), researchers studying changes in moral behavior and judgment from childhood to adulthood. Yet social existence in the community requires standards within the individual as well as an agreement about standards among groups of individuals. As Kluckhohn (1951, p. 400) once pointed out, without values, “the functioning of the social system could not continue to achieve group goals;
individuals . . . could not feel within themselves a requisite measure of order and unified purpose.” A group’s culture provides such a set of enduring values. By adding an ele- ment of collective purpose in social life, values most often guarantee endurance and stability in social existence.
Hierarchical System
Isolated values usually are organized into a hierarchical sys- tem in which certain values have more weight or importance than others. For instance, in a team sport such as baseball, values regarding individual performance, batting and run- ning records, speed, and throwing and catching all fall into a hierarchy, with the values of team and winning being at the 74
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top. As an individual confronts social situations throughout life, isolated values learned in early childhood come into competition with other values, requiring a weighing of one value against another. Concern for others’ welfare, for instance, competes with self-interest. Through experience and maturation, the individual integrates values learned in different contexts into systems in which each value is ordered relative to other values (Glasser, 1998).
Prescriptive–Proscriptive Beliefs
Rokeach (1973) described values as a subcategory of beliefs.
He argues that some beliefs are descriptive or capable of being true or false (e.g., the chair on which I am sitting will hold me up). Other beliefs are evaluative, involving judg- ments of good and bad (e.g., that was an excellent lecture).
Still other beliefs are prescriptive–proscriptive, determining whether an action is desirable or undesirable (e.g., this music is too loud, those baseball fans shouldn’t yell when the pitcher is winding up). Values, Rokeach says, are prescrip- tive–proscriptive beliefs. They are concerned with desirable behavior or “what ought to be.” For example, parents’ values about child behavior determine how they choose to discipline their children, using either corporal punishment or a time- out. Some parents believe that their 2-year-old child has the capacity to control his bladder, and when the child wets his pants they are being “rebellious” and should be punished.
Values have cognitive, affective, and behavioral components.
According to Rokeach, to have a value, it is important to know the correct way to behave or the correct end state for which to strive (cognitive component); to feel emotional about it—to be affectively for or against it (affective compo- nent); and to take action based on it (behavioral component).
Reference
Values also have a reference quality. That is, they may refer to end states of existence called terminal values, such as
spiritual salvation, peace of mind, or world peace, or they may refer to modes of conduct called instrumental values, such as confidentiality, keeping promises, and honesty. The latter can have a moral focus or a nonmoral focus, and these values may conflict. For example, a nurse may experience a conflict between two moral values, such as whether to act honestly (tell a client about a fatal diagnosis) or to act respectfully (honor the family’s request not to tell the client). Similarly, the nurse may experience conflict between two nonmoral values, such as whether to plan logically (design a traditional group interven- tion for mental health clients) or to plan creatively (design an innovative field experience). The nurse also may experience conflict between a nonmoral value and a moral value, such as whether to act efficiently or to act fairly when establishing pri- orities for funding among community health programs.
Adults generally possess only a few—perhaps no more than 20—terminal values, such as peace of mind or achieve- ment. These are influenced by complex physiologic and social factors. The needs for security, love, self-esteem, and self-actualization, proposed by Maslow (1969), are believed to be the greatest influences on terminal values. Although an individual may have only a few terminal values, the same person may possess as many as 50 to 75 instrumental values.
Any single instrumental value, or several instrumental val- ues combined, also may help to determine terminal values.
For example, the instrumental values of acceptance, taking it easy, living one day at a time, and not being concerned about the future can shape the terminal value of peace of mind; whereas the instrumental values of hard work, driving oneself to compete, and not letting anyone get in the way can influence the terminal value of achievement. Figure 4.3 illustrates the influence of instrumental values and human needs on the development of terminal values.
Preference
A value may show preference for one mode of behavior over another, such as exercise over inactivity, or it may show a CHAPTER 4 Evidence-based Practice and Ethics in Community Health Nursing
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75Terminal Values Instrumental
Values
Self-actualization
Social expectations Environment
Honesty
Frugality
Promise-keeping
Confidentiality
Self-esteem Economics
Culture
Security
Love
Physiolog ical nee
ds
F I G U R E 4.3 Factors influencing personal values.
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preference for one end state over another, such as physical fitness and leanness over sedentary lifestyle and obesity. The preferred end state, or mode of behavior, is located higher in the personal value hierarchy.
Value Systems
Value systemsgenerally are considered organizations of beliefs that are of relative importance in guiding individual behavior (Rokeach, 1973). Instead of being guided by single or isolated values, however, behavior at any point in time (or over a period of time) is influenced by multiple or changing clusters of values. Therefore, it is important to understand how values are integrated into a person’s total belief system, how values assume a place in a hierarchy of values, and how this hierarchical system changes over time.
Hierarchical System of Values
Learned values are integrated into an organized system of values, and each value has an ordered priority with respect to other values (Rokeach, 1973). For example, a person may place a higher value on physical comfort than on exercising.
This system of ordered priority is stable enough to reflect the continuity of someone’s personality and behavior within cul- ture and society, yet it is sufficiently flexible to allow a reordering of value priorities in response to changes in the environment or social setting (e.g., society’s emphasis on physical fitness and youth) or changes based on personal experiences (e.g., diagnosis of type 2 diabetes). Behavioral change would be regarded as the visible response to a reordering of values within an individual’s hierarchical value system.
Conflict Between Values in a System
When an individual encounters a social situation, several values within the person’s value system are activated, rather than just a single value. Because not all of the activated val- ues are compatible with one another, conflict between values occurs. This conflict between values is a part of the decision- making process, and resolving these value conflicts is crucial to making good decisions. Community health nurses face conflicting values when they seek to promote the well being of certain individuals, a result that may come at the expense of the public good. Even within a single community agency, nurses may find that they prioritize client service or pro- gramming values differently.
Some values seem to consistently triumph over oth- ers, persisting as stronger directives for individual behav- ior; an example is the value placed on high achievement in the United States. It is this persistence on the part of some values (e.g., individualism versus community) that makes universal coverage and other issues so controversial in health care reform (Axtell-Thompson, 2005). Other val- ues lose their positions of importance in a value hierarchy (e.g., resuscitation of all hospital patients versus do not resuscitate orders [DNRs]). It is this changing arrange- ment of values in a hierarchical system that determines, in part, how conflicts are resolved and how decisions are made. In this way, people’s value systems function as a learned organization of principles and rules that help them
to choose among alternative courses of action to reach decisions.
Values Clarification
One way to understand the influence and priority of values in your own behavior, as well as in that of community health clients, is to use various values clarification techniques in decision-making. Values clarification is a process that helps to identify the personal and professional values that guide your actions, by prompting you to examine what you believe about the worth, truth, or beauty of any object, thought, or behavior and where this belief ranks compared with your other values (Feldman-Stewart, Brennenstuhl, Brundage, &
Roques, 2006). Because individuals are largely unaware of the motives underlying their choices, values clarifica- tion is important for understanding and shaping the kind of decisions people make. Only by understanding your val- ues and their hierarchy can you ascertain whether your choices are the result of rational thinking or of external influences, such as cultural or social conditioning. Values clarification by itself does not yield a set of rules for future decision-making and does not indicate the rightness or wrongness of alternative actions. It does, however, help to guarantee that any course of action chosen by people is con- sistent and in accordance with their beliefs and values (Red- man, 2001; Guido, 2006).
Process of Valuing
Before values clarification can take place, it must be under- stood how the process of valuing occurs in individuals. In 1977, Uustal listed the following seven steps, which remain useful today:
1. Choose the value freely and individually.
2. Choose the value from among alternatives.
3. Carefully consider the consequences of the choice.
4. Cherish or prize the value—feel good about the choice.
5. Publicly affirm the chosen value.
6. Incorporate the value into behavior, so that it becomes a standard or a pattern of behavior.
7. Consciously use the value in decision-making.
These steps provide specific actions for the discovery and identification of people’s values. They also assist the decision-making process by explicating the process of valu- ing itself. For example, some people may choose to value honesty in a presidential candidate. They choose this over other values, such as knowledge of foreign affairs or public speaking ability, because, considering the consequences, they want a leader who will deliver on promises made, who will continue to be the person represented to the public dur- ing the campaign. They prize this value of honesty, affirm it publicly, and consciously use it as a standard when deciding on whom to vote into office or to reject.
Values Clarification Strategies
In 1978, Uustal offered several values clarification strategies that are ultimately useful to the decision-making process in community health nursing practice today. Strategy 1 is a way 76
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for nurses to come to know themselves and their values bet- ter (Fig. 4.4). Strategy 2 assists in discovering value clusters and the priority of values within personal value systems (Fig. 4.5). Strategy 3 can be used to examine personal responses to selected issues in nursing practice. Each response helps to establish priorities of values by asking the nurse to choose among the alternatives presented or to
indicate degree of agreement or disagreement (Fig. 4.6).
Other values clarification strategies are included in the crit- ical thinking activities at the end of this chapter to assist in understanding personal ordering of values and when consid- ering directions for change. These strategies also help the nurse to assist community health clients to become clearer about their own values.
All of these strategies can be used to analyze and understand how values are meaningful to people and ulti- mately influence their choices and behavior. Clarification of a person’s values is the first step in the decision-making process, and it affects the ability of people to make ethical decisions. Values clarification also promotes understanding and respect for values held by others, such as community health clients and other health care providers. As pointed out by Uustal (1977, p. 10), “Nurses cannot hope to give opti- mal, sensitive care to any patient without first understanding their own opinions, attitudes, and values.” This values clari- fication process provides a backdrop for next exploring the role of values in ethical decision-making.