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Letter to the Editor

Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk

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Abstract

Healthcare professionals often face complex ethical dilemmas in the workplace. Some professionals confront the ethical issues directly while others turn away. Moral courage helps individuals to address ethical issues and take action when doing the right thing is not easy. In this article the author defines moral courage, describes ongoing discussions related to moral courage, explains how to recognize moral courage, and offers strategies for developing and demonstrating moral courage when faced with ethical challenges

Citation: Murray, J.S., (Sept 30, 2010) "Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Manuscript 2.

DOI: 10.3912/OJIN.Vol15No03Man02

Key words: Moral courage, ethics, ethical dilemmas, developing moral courage, Code of Ethics for Nurses, Nursing’s Social Policy Statement, cultural diversity

"Stand up for what is right even if you stand alone." Anonymous

There are few articles addressing moral courage in today’s healthcare literature. Examples of unethical behaviors are seen today in academia, politics, sports, entertainment, banking, and the legal system (Gallup, 2009; Kidder, 2005; Murray, 2007a; 2007b; Zangaro, Yager & Proulx, 2009). Healthcare professionals working in clinical practice, education, research, and administration are not immune to these unethical behaviors. They face ethical dilemmas on a regular basis. Shortages in the numbers of clinicians to deliver patient care, inadequate staffing levels, cost containment measures, consolidation of healthcare organizations, and ineffective leadership have resulted in the escalation of ethical dilemmas nurses face today in healthcare environments (Clancy, 2003; Einarsen, Aasland & Skogstad, 2007; Murray, 2008; 2007aZangaro et al., 2009). How individuals respond to these ethical dilemmas depends on their previous experiences with unethical behavior, their individual personality traits, and their ethical values, as well as their knowledge of ethical principles (Clancy, 2003). Moral courage is needed to confront unethical behaviors. The following exemplar demonstrates moral courage in clinical practice.

 

Emily was a novice nurse employed at an academic medical center. Her peers respected her and described her as an attentive and meticulous nurse with strong work values. Over time Emily noted a behavior in the work setting that concerned her and conflicted with her ethical principles. She had observed her supervisor falsifying training records of nurses still on orientation so that these new nurses could begin earlier to work independently, thus improving staffing levels. When Emily brought this behavior to the attention of the more senior nurses on the unit, they explained that they experienced retaliation if they even mentioned this misconduct. After much deliberation, Emily felt that she had an ethical responsibility to take action and bring this matter to the attention of the hospital administration. As soon as she did this, her supervisor began to berate her in staff meetings, change her work schedule unfairly and without notice, withhold needed information, set unreasonable deadlines, and prevent her opportunities for professional advancement. Recognizing that nurses have an obligation to always demonstrate the highest professional and ethical standards, Emily sought guidance from the medical center’s nurse ethicist. This guidance and support helped her to stand firm and stay resolute in her determination to do what was right.

 

There are few articles addressing moral courage in today’s healthcare literature. What is available indicates a lack of moral courage on the part of healthcare professionals when they are faced with ethical challenges (Aultman, 2008). Sekerka and Bagozzi (2007) have encouraged healthcare organizations to promote ‘ethical fitness’ so as to increase providers’ level of moral courage in daily organizational activities. Healthcare agencies and professional organizations need to articulate, encourage adherence to, and act on shared values as they provide an environment in which moral behaviors are welcomed and expected. The challenge in today’s constantly changing healthcare environment is to be certain that professionals understand what moral courage is, why it is important for all settings in which they practice, teach, research, and/or lead, and how moral courage can be demonstrated when ethical challenges are confronted (Purtilo, 2000). In this article the author defines moral courage, describes ongoing discussions related to moral courage, explains how to recognize moral courage, and offers strategies for developing and demonstrating moral courage when faced with ethical challenges.

Moral Courage Defined

Scholars have debated the various meanings of ‘courage’ over the centuries. Ancient Greek philosophers, such as Plato and Aristotle, frequently used the term in reference to character on the battlefield. Plato and Aristotle discussed courage as a trait set aside for situations where individuals feared death. Aristotle specifically discussed courage in the context of being able to wage war while being mindful of the possibility of injury or death. To Aristotle, bravery was a virtue that enabled Greek soldiers to respond appropriately to the fear of the battle (Day, 2007; Lachman, 2007; Miller, 2005).

Morally courageous professionals persevere to stand up for what is right even when it means they may do so alone. While the ancient Greeks described courage as a desired response to physical danger, contemporary scholars more frequently address courage as the commitment to stand up for/act upon one’s ethical beliefs – an essential virtue for all healthcare professionals today (Clancy, 2003Day, 2007; Kidder, 2005; Lachman, 2009; 2007a; Purtilo, 2000). This type of courage, called moral courage, is vital to the willingness of individuals to take hold of, and fully support, ethical responsibilities essential to professional values (Day, 2007). Moral courage is a highly esteemed trait displayed by individuals, who, despite adversity and personal risk, decide to act upon their ethical values to help others during difficult ethical dilemmas. These individuals strive to do the right thing, even when others chose a less ethical behavior, which may include taking no action at all (Lachman, 20092007a; 2007bSekerka & Bagozzi, 2007). Morally courageous professionals persevere to stand up for what is right even when it means they may do so alone. The ultimate goal of morally courageous behavior is to put ethical principles into action and protect ethical values perceived to be at risk (Kidder, 2005Purtilo, 2000; Secretan, 2009: SG Solutions, 2009).

Moral courage is considered to be the pinnacle of ethical behavior; it requires a steadfast commitment to fundamental ethical principles despite potential risks, such as threats to reputation, shame, emotional anxiety, isolation from colleagues, retaliation, and loss of employment. Morally courageous individuals are prepared to face tough decisions and confront the uncertainties associated with their resolve to do the right thing despite the consequences they may face (Clancy, 2003Kidder, 2005; Lachman, 2007a; 2007c; Miller, 2005; Peake, 2006).

Discussions Related to Moral Courage

While the Code of Ethics for Nurses encourages nurses to remain consistent with their own personal values, it also emphasizes the need for open discussion of differing ethical principles... It is important not to confuse moral courage with moral arrogance and moral certitude (moral certainty). Moral arrogance involves truly believing that one’s own moral stand or judgment is the only correct option regarding a controversial issue, even though others consider differing moral decisions or judgments to be morally acceptable (Gert, Culver, & Clouser, 2006). Morally arrogant individuals are condescending, dismissive of the thoughts of others, and primarily concerned with self (Baylis, 2007). Moral certitude (or certainty) is the term used to describe a very firm belief based on an inner conviction. Morally certain individuals believe that they are correct in their beliefs to the extent that they have no reservations whatsoever about the rightness of their beliefs. Moral arrogance and moral certitude inhibit the thoughtful assessment needed in ethical practice. These attitudes bring with them the risk of suppressing open dialogue and forthright deliberation regarding ethical issues. In contrast, professional and ethical principles, rather than personal preconceptions or unwavering preferences, should serve as the foundation of ethical decision making (Vaiani, 2009). The American Nurses Association (ANA) Code of Ethics for Nurses (2001) contains a common, shared set of ethical principles to guide nurses’ professional behavior. All nurses are encouraged to hold to these principles in their practice of professional nursing. While the Code of Ethics for Nurses encourages nurses to remain consistent with their own personal values, it also emphasizes the need for open discussion of differing ethical principles in a manner that does not consistently place one principle above another, thus avoiding the dangers of moral arrogance and moral certitude.

There is also much debate over the difference between public and private morals. The Code of Ethics for Nurses (ANA, 2001) addresses the distinction between public and private morals. Provision Five of the Code discusses wholeness of character whereby, in the course of becoming a professional nurse, nurses accept the values of the profession integrating them with their personal value system (ANA, 2001). Additionally, Nursing’s Social Policy Statement provides guidance regarding nursing’s relationship with society as well as a nurse’s professional obligation to the public (ANA, 2003). This statement notes that nurses are encouraged to use these guidelines to promote an awareness of their relationship with the public. Nursing is a critical component of the general public from which the profession has grown and continues to grow. Nurses are expected to conduct themselves in an ethical and responsible manner, mindful of the trust instilled upon them by society (ANA, 2003).

...nurses who bring varying cultural customs, philosophical views, and ethical principles to the professional setting can strengthen and broaden healthcare delivery as they help their colleagues understand differing perspectives... Another discussion centers on the question of whether moral courage is a universal or a culturally dependent term. There is a paucity of literature addressing this question. Yet many have found that immigration to a new country poses unique challenges, including an adjustment to a variety of different customs. These challenges can be especially difficult for nurses who struggle both to become accepted into a new society and to exercise moral courage in an unfamiliar environment. Scholars of moral courage have addressed the question of whether there is a common moral framework that exists across cultures. While it is evident that values and principles vary worldwide, scholars point to ethical values that are shared across cultures, such as honesty, integrity, fairness, respect, responsibility, empathy, compassion, and courage. The scholars who study moral courage, however, have observed that diverse cultures place different priorities on these ethical principles. They call for additional research to address the manner in which these ethical principles are put into practice across various cultural settings (Bjarnason, Mick, Thompson, & Cloyd, 2009; Chatham-Carpenter, 2006; Miller, 2005).

The ANA’s 1991 Position Statement addressing cultural diversity in nursing practice helps health professionals understand how nurses’ cultural backgrounds can influence the care they give. This position statement has noted that nurses who bring varying cultural customs, philosophical views, and ethical principles to the professional setting can strengthen and broaden healthcare delivery as they help their colleagues understand differing perspectives regarding illness and treatment modalities (ANA, 1991). As nurses increase their understanding of differing perspectives regarding health, illness, and ethical values, they can better respect and work to integrate these perspectives into the care they provide (ANA, 2001Bjarnason, Mick, Thompson, & Cloyd, 2009).

Recognizing Moral Courage

Moral courage is seen in individuals who, when they uncover an ethical dilemma, explore a course of action based on their ethical values, and follow through with a decision as to the right course of action regardless of the possible consequences this course of action might present. Moral courage generally occurs when individuals with high ethical standards face acute or recurring pressures to act in a way that conflicts with their values (Clancy, 2003Miller, 2005). Moral courage can be seen in a staff nurse such as Emily (described above), who, when under pressure from administration, refuses to document patient care that wasn't provided; in a researcher who declines to engage in scientific misconduct for the purpose of receiving funding to help the organization enjoy better standing in the research community; or in an academician who rejects unrelenting demands to pass failing students despite threats to tenure (Murray, 2007a). All of these healthcare professionals exemplify moral courage in doing what they believe is ethically correct.

Developing Moral Courage in the Face of Ethical Challenges

The lack of moral courage seen today across many sectors of society provides evidence as to why this virtue requires development (Aultman, 2008; Sekerka & Bagozzi, 2007). Scholars have questioned whether or not moral courage is instinctive or a trait that is learned. Aristotle in particular argued that moral virtues are teachable (Day, 2007; Miller, 2005). Most scholars who study ethics agree with Aristotle that everyone, regardless of profession, can benefit from education and training in the area of moral courage (Kidder, 2005).

Strategies for developing moral courage include open dialogue about ethical principles and systems, case studies, role modeling by real-life exemplars, and rehearsals in which learners practice what they have learned in order to build their skills related to moral decision making (Aultman, 2008Kidder, 2005; Purtilo, 2000). This requires a continuous commitment to, and reflection upon personal values and moral behaviors that influence ethical decision making (Clancy, 2003Kidder, 2005). Moral courage can only be developed and strengthened through regular application (Miller, 2005).

Healthcare professionals need to recognize their responsibility to address unethical behaviors in the workplace (Murray, 2007; Saver, 2009). When nurses are mentored in developing moral courage, they come to learn and take-hold-of new behaviors, such as taking action when unethical behaviors are observed. Ethics consultants, healthcare educators, and researchers are encouraged to provide guidance and pedagogical tools that enable professional providers to understand and implement morally courageous behaviors and demonstrate exemplary personal and professional standards of ethical behavior (Purtilo, 2000; Sekerka & Bagozzi, 2007).

Academic programs at the undergraduate and graduate levels, internships, fellowships, and continuing education programs in which participants dialogue about ethical dilemmas can serve to develop moral courage. Healthcare organizations that acknowledge the importance of following ethical principles can create an expectation that morally courageous behavior will occur when personnel face ethical dilemmas that threaten deeply held values pertinent to the work environment (Purtilo, 2000). Furthermore, hospitals, academic institutions, research centers, and professional organizations are encouraged to make resources related to moral courage available to all healthcare providers. Valuable resources include professional journal articles, textbooks, and continuing educational offerings, along with institutional policies that support an ethical environment (Aultman, 2008; Murray, 2008; 2007a). Table 1 lists a number of websites offering resources to strengthen moral courage among healthcare professionals.

Table 1. Resources on Moral Courage

Organization

Website

Foundation of Moral Courage

www.moralcourage.org/

The Moral Courage Project

www.moralcourage.com/

Moral Courage: Ethics in Action

www.moralcourage.com/

Institute for Global Ethics

www.globalethics.org/

American Society for Bioethics and Humanities

www.asbh.org/

American Nurses Association Center for Ethics & Human Rights

www.nursingworld.org/MainMenuCategories/EthicsStandards/About.aspx

Demonstrating moral courage when confronted with ethical misconduct is critical to good professional practice whether in a clinical setting, the classroom, a research laboratory, or the boardroom (Day, 2009). Table 2 presents critical checkpoints to assist healthcare professionals demonstrate moral courage in healthcare settings.

Table 2. Critical Checkpoints in using Moral Courage for Ethical Decision Making

Steps

Checkpoint

1

Evaluate the circumstances to establish whether moral courage is needed in the situation

2

Determine what moral values and ethical principles are at risk or in question of being compromised

3

Ascertain what principles need to be expressed and defended in the situation – focus on one or two of the more critical values

4

Consider the possible adverse consequences/risks associated with taking action

5

Assess whether or not the adversity can be endured – determine what support/resources are available

6

Avoid stumbling blocks that might restrain moral courage, such as apprehension or over reflection leading to reasoning oneself out of being morally courageous in the situation

7

Continue to develop moral courage through education, training, and practice

(Adapted from Kidder, 2005, p. 17)

A number of challenges can circumvent moral courage. Individuals should be familiar with the behaviors that have the potential to disrupt morally courageous actions. Table 3 offers examples of inhibitors of moral courage.

Table 3. Inhibitors of Moral Courage

  1. Organizational cultures that stifle discussion regarding unethical behaviors and tolerate unethical acts
  1. Willingness to compromise personal and professional standards in order to avoid social isolation from peers or to secure a promotion/favoritism within the organization
  1. Unwillingness to face the tough challenge of addressing unethical behaviors
  1. Indifference to ethical values
  1. Apathy of bystanders who lack the moral courage to take action
  1. Group think that supports a united decision to turn the other way when unethical behaviors are taking place
  1. Tendency to redefine unethical behaviors as acceptable

(Adapted from Kidder, 2005, p. 211)

Conclusion

It is important that all healthcare professionals value and support their peers who have the courage to stand up and speak out against unethical behavior even when others are silent or differ in opinion. This article has highlighted the critical need for healthcare professionals who both understand the importance of moral courage in the workplace and are willing to take action when ethical values are being compromised. An awareness of the importance of moral courage and factors that support/inhibit moral courage can help clinicians, educators, researchers, and leaders in healthcare demonstrate moral courage when they face ethical challenges and uphold ethical environments (Murray, 2007a; Sekerka & Bagozzi, 2007). It is important that all healthcare professionals value and support their peers who have the courage to stand up and speak out against unethical behavior even when others are silent or differ in opinion.

Professional nursing organizations should encourage members to take actions that create and sustain ethical environments and support protections for those who choose to confront unethical behaviors in the workplace (Murray, 2007a; 2010Sekerka & Bagozzi, 2007). All levels of educational programs, and also continuing education programs are encouraged to address the need for moral courage and to teach strategies that enable healthcare providers to act courageously when ethical standards are compromised. Healthcare institutions can address moral courage and ethical principles in their position descriptions, performance appraisals, and strategic planning sessions. It is essential that the healthcare industry develop leaders with strong ethical values, leaders who are willing to live these values with integrity and courage, even when doing so risks their professional relationships and their position in their organizations (Murray, 2010).

Author

Colonel John S. Murray, PhD, RN, USAF, NC
E-mail: JMurray325@aol.com

Colonel (Dr.) John S. Murray is the Director of Education, Training & Research, Joint Task Force National Capital Region Medical, Bethesda, MD. He earned a Bachelor of Science in Nursing from Northeastern University (Boston); a master’s degree in pediatric acute and chronic care nursing from Boston College; a post-master’s degree in pediatric primary care from the University of Texas Medical Branch; and a PhD in Nursing from the University of Texas at Austin. Dr. Murray is also a member of the American Nurses Association Ethics and Human Rights Advisory Board and President of the Federal Nurses Association. In these roles he has authored resolutions for ANA and peer-reviewed articles for professional journals addressing workplace abuse and harassment of nurses. He is now working on legislation to protect nurses who report workplace abuse and harassment. In 2008, Dr. Murray was a nominee for The John F. Kennedy Profile in Courage Award, the nation's most prestigious honor awarded to individuals whose actions best demonstrate the qualities of politically and morally courageous leadership, for his efforts related to workplace ethics.

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© 2010 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2010


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