Moral Courage: A Virtue in Need of Development? - American ...

Ethics, Law,and PolicyVicki D. LachmanMoral Courage: A Virtue inNeed of Development?Moral distress has been documented since 1984 byAndrew Jameton. He defined it as painful feelingsand/or the psychological disequilibrium that occurswhen nurses are conscious of the morally appropriateaction a situation requires, but cannot carry out theaction because of institutional obstacles (Corley,Minick, Elswick, & Jacobs, 2005). This definition focuseson organizational obstacles to action, but there arealso personal obstacles that the nurse must conquer(for example, lack of knowledge of professional obligations,lack of conflict resolution skills, etc.).This author’s interest is not in discussing the existenceof moral distress, but instead how to preventand rectify the pain and suffering caused by moral distress.To this purpose, this article we will focus onnecessary ingredients for moral courage. Interestedreaders can gain additional understanding of theproblems created when organizational culture trumpscourage by reading the story of Enron (McLean &Elkind, 2004). We will first define moral courage andthen, using an acronym CODE, outline the work fornurses who are interested in demonstrating moralcourage.Moral Courage DefinedIn 350 BC, Aristotle defined courage as the balancebetween cowardice and rashness. He believedthat the virtue of courage must be understood as bothan end in itself and a means to a more wide-ranginggood. He saw courage as necessary for achievementof all other virtues. He stated, “Courage is the first ofhuman qualities because it is the quality which guar-Vicki D. Lachman, PhD, APRN, MBE, is an AssociateProfessor, Drexel University, Philadelphia, PA.Editor’s Note: Dr. Vicki D. Lachman is the new editor of thecolumn, “Ethics, Law and Policy.” She is the author ofApplied Ethics in Nursing (2006). This is the first of two articleson moral courage. The second article in June will focuson the application of moral courage in four clinical casesfamiliar to medical-surgical nurses. Dr. Lachman is open torequests for topics at vdl22@drexel.edu.antees the others.” However, Aristotle’s primary focuswas on physical courage needed in warfare, not onmoral courage.Moral courage is the individual’s capacity toovercome fear and stand up for his or her core values.It is the willingness to speak out and do thatwhich is right in the face of forces that would lead aperson to act in some other way. It puts principlesinto action. Physical harm could be a threat in casesof moral courage; however, the more likely risks arehumiliation, rejection, ridicule, unemployment, andloss of social standing. However, this personal sacrificeoften is accompanied by a sense of peacebecause the individual stood up for a non-negotiableprinciple. Moral courage enables individuals toadmit to wrongdoing and ethical dilemmas steadfastlyand self-confidently.Moral courage in the face or wrongdoing (“rightversus wrong”) may appear initially easier than theethical dilemmas of “right versus right.” Wrongdoingis best understood as illegal behavior or professionaland personal misconduct, such as lying, irresponsibility,or unfairness (Kidder, 2005). However, confrontinga physician who has deceived a patient onprognosis or confronting a colleague who comes towork impaired by alcohol is far from easy. Whenthese core ethical issues of honesty and responsibilityare violated or disregarded, the situation islabeled “right versus wrong.”In “right versus right” situations, ethical issuesemerge when core values conflict with each other.However, ethics is not a hard science such as geometry.The principles used may blur into one anotheralong the boundaries of the dilemma, leaving peoplewavering when trying to assert a conclusion. Thisconundrum speaks to the importance of knowingprofessional ethical obligations and non-negotiablepersonal values.For example, in the first instance above, thenurse has the obligation to support the physicianpatientrelationship and to support the patient’sright to information for informed consent. The Codeof Ethics for Nurses (American Nurses Association[ANA], 2001) addresses both of these obligations. InMEDSURG Nursing—April 2007—Vol. 16/No. 2 131

the second example, the nurse has the obligation“…to protect the patient, the public and the professionfrom potential harm when a colleague’s practice,in any setting, appears to impaired” (ANA, 2001,p.15). The nurse may experience an ethical conflictbecause the organization does not address impairedpractice in a compassionate way, as the Code directs(ANA, 2001). Instead, administrators fire the nurses.As can be seen by these two examples, a “right versuswrong” situation, upon further examination, mayactually be a “right versus right” case.Acronym for Moral CourageAn acronym often is helpful in remembering thecomponents of a process. CODE will be used to suggestthe foundation necessary for moral courage (seeFigure 1). This acronym also serves as a reminder ofthe professional obligations of nurses, as outlined inthe Code of Ethics for Nurses (ANA, 2001).Obligations to HonorCourage to be moral requires a definition of whatit means to be moral. If “moral” implies that which isgood, then moral courage also means the courage tobe ethical. Lists of ethical duties and obligations ashumans, nurses, parents, and community membersabound. How can anyone know which ones are mostimportant to honor?The Code of Ethics for Nurses (ANA, 2001) conveysthe values and obligations regulating the conductof nurses in relation to their patients, colleagues,communities, and the nursing profession.Unfortunately, this code is grossly underutilized ineveryday nursing practice. Why? Because few nursesrecognize they are obligated to this non-negotiable,professional ethical standard, simply by calling themselvesregistered nurses. Once aware of these obligations,each nurse must find within his or her own consciencethe moral courage to honor these obligations.What other guidance can be offered to nurses?Institute for Global Ethics, through years of surveyresearch, narrowed the list of moral values to themost important five: honesty, respect, responsibility,fairness, and compassion (Kidder, 2005). These fivevalues help structure a definition of what is moral.Beauchamp and Childress (2002) formulated a set ofprinciples for a common morality framework. Thisfour-principle approach consists of autonomy, beneficence,nonmaleficence, and justice. These are allfamiliar to health care professionals because professionalcodes incorporate them into their rules of etiquetteand responsibilities.For example, both principlism and the Code ofEthics for Nurses (ANA, 2001) address autonomy, orthe right to self-determination. The first provision ofthis code articulates the moral obligations of nursesin informed consent.Patients have the moral and legal right to determinewhat will be done with their own persons;to be given accurate, complete, and understandableinformation in a manner that facilitates aninformed judgment; to be assisted with weighingbenefits, burdens, and available options in theirCODEFigure 1.CodeCourage to be moral requires:Obligations to honor (What is the right thing to do?)Danger to manage (What do I need to handle myfear?)Expression and action (What action do I need totake to maintain my integrity?)treatment, including the choice of no treatment;to accept, refuse, or terminate treatment withoutdeceit, undue influence, duress, coercion, orpenalty; and to be given necessary supportthroughout the decision-making and treatmentprocess (p. 8).The code continues to spell out the ethical obligationof the nurse in supporting autonomy with areminder of the importance of capacity, culture, andthe role of surrogates. However, good moral choicesdepend on more than these values or ethical principles;these choices require the courage to act. This isa point Confucius made in saying, “To see what isright, and not do it, is a want of courage or of principle.”Courage requires the management of fear.Danger to ManageWhere danger is present, there is need forcourage. In moral courage, danger is accepted for thesake of a commitment to conscience, ethics, or corevalues. This author has observed that two importantskills are necessary to tolerate the fear generated bythe perceived danger. The first is self-soothing, whichinvolves a combination of relaxation and cognitivereframing strategies. The second skill is the ability toassess the risk involved in standing up for moral convictions.First, the nurse must find ways to calm the innerfear, so it does not paralyze frontal cerebral function.Fear activates the “fight or flight response” and thiscould trigger timidity or rashness. This author hasobserved that a few stand-by strategies work to calmthe physiological response, such as deep breathing,counting backwards from 10 slowly, and visualizationand calming inner words (for example, “I amfine. I can manage this situation”).The cognitive reframing strategies involve firstan awareness of the individual’s thoughts and then achange to thoughts that would better serve that personin solving the problem. It is important to rememberthat the emotion an individual experiencesdepends on his or her self-talk about the situation orabout the other people involved. For example, theindividual’s use of catastrophizing suggests anexpected disaster, such as being fired. In reality,what are the odds a physician could have a nursefired for questioning the overestimation of a prognosisfrom a certain treatment? Because it is crucial tomanage emotions triggered by the danger, the authorsuggests several practical books that could provehelpful in managing emotions (Fisher & Sharp, 2004;Meyer, 2004; Schinnerer, 2006; Thomas, 2003;Thomas & Petracek, 2004).132 MEDSURG Nursing—April 2007—Vol. 16/No. 2

Second, the nurse must assess the risk in standingup in a situation involving the need for moralcourage. Risk taking is doing something because theindividual believes that what is gained is better thanwhat he or she has (Tulloch & Lupton, 2003). Thoughthe person is entering uncharted territory — theunknown, the uncertain — he or she believes theoutcome will be worth the effort. In taking a risk, theindividual learns and gains confidence by facing achallenge that will demand personal courage or faithin self or others. One of the paradoxes of life is thatgenuine security requires risk taking.An individual may experience obligations as acertainty, but uncertainty in outcome. Therefore, thenurse also must assess the risk in the consequencesflowing from the possible alternatives. Though allrisks involve some ambiguity and potential for loss,taking action based on both rational thought andintuition decreases the peril. Ambiguity can bereduced by obtaining more information and consultingwith people who are less emotionally attached tothe outcome. Choosing options others can supportand forming alliances with other colleagues canreduce exposure to loss. Finally, risks should not beconsidered without constructing the worst case scenarioand having a contingency plan to cope with theoutcome. Resolving wrenching moral choicesrequires the willingness to persevere in ethicalchoice, even though the journey is unknown.Expression and ActionMoral courage is a means to triumph over fearthrough practical action. Knowing professional obligationsand personal values is not the same as communicatingand acting on those obligations and values.The space between knowing and acting is bridged bymoral courage. To quote Martin Luther King, Jr., “Ourlives begin to end the day we become silent about thethings that matter.”What skills are needed to express and act onobligations, as well as manage the fear? This authorhas observed that many times the expression and/oraction will run counter to the established norms ofthe group or organization, therefore, the individualwill need both assertiveness and negotiation skills.These skills are necessary for managing the conflictthat often ensues when a person dares to say or dosomething counter to the traditions and customs ofthe majority. Resources to develop these skills areprovided (Kritek, 2002; Mayer, 2006; Patterson,Grenny, McMillan, & Switzler, 2002; Ursiny, 2003).However, because conflict resolution is a skill,the more the nurse practices, the better he or shegets at resolving disagreements. Not only will theseactions provide experience, but they will build character;both will help the individual persevere in conflict.Aristotle said, “Man acquires a particular qualityby constantly acting a particular way...we becomejust by performing just actions, we become temperateby performing temperate actions, brave by performingbrave actions.”Besides using practice to attain moral courage,the nurse can turn to mentors to model and coach inachieving the skills. The individual can engage in dialoguewith seasoned nurses who have faced a multitudeof “right versus wrong” and “right versus right”experiences. Reading biographies of individuals whohave demonstrated moral courage also may be helpful.Learning to express and act with moral couragecan be learned from a variety of sources.ConclusionThe individual with moral courage knows therewards are unlike those that come from blind resolveor from safe harbors. He or she abides by principles inthe face of danger, taking the time to determine theright thing to do. This nurse knows his or her professionalobligations and stands firm in core values thathonor patients, profession, and self. The nurse hasnot acted impulsively, but has assessed the risk ofaction, used effective conflict resolution skills, andsought moral resolution. The nurse with moralcourage is willing to endure the fear and act, even atpersonal cost. They agree with Amelia Earhart’s commentthat “courage is the price that Life extracts forgranting peace.” ■ReferencesAmerican Nurses Association (ANA). (2001). Code for ethics for nurseswith interpretative statements. Silver Spring, MD: AmericanNurses Publishing.Beauchamp, T.L., & Childress, J.F. (2002). Principles of biomedicalethics (5 th ed.) New York: Oxford University Press.Corley, M.C., Minick, P., Elswick, R.K., & Jacobs, M. (2005). Nursemoral distress and ethical work environment. 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