By Tore Audun Høie, author of Health Management (Norwegian Helseledelse)
Nursing is an important profession, and a lack of nurses could become a fundamental problem in the future. Nursing is perhaps also a key example of virtue ethics in practice.
Ethics are often divided into three types, based on rules, utility or virtue. The virtue aspect has traditionally been a little unclear, but a good illustration is the fact that nurses choose a profession that is difficult, stressful and not well paid despite good high school marks. Perhaps a driver is the wish to help?
More generally virtue ethics may be seen as “doing the right thing” instead of what is comfortable or confers personal advantages. The challenge is knowing what is the right thing to do.
Nurses have an ethical code outlining their tasks and social role, perhaps the best ethical code in Norway. The Norwegian Nurse Association had the following goals for 2012:
To influence society to improve population health
To influence health development preparing for, preventing and solving population health problems
To influence health services to satisfy population demands and needs regarding quality and availability
To work to realize the goal of equality between women and men in all areas
To further international understanding and solidarity, and work for a society built on multicultural understanding and civil rights
Professional codes are normally a bit superficial and remote, but it is difficult to imagine a better set than those above. Economists and lawyers have more difficulties explaining their societal role.
All three forms of ethics have advantages and drawbacks. Virtue ethics ensure that a person is addressing higher goals than their own comfort; quality is a natural extension of that. Health reform in Norway initially ignored quality, but subsequently the concept of quality became a key health issue, especially in the field of patient security.
Central to maintaining quality is to report errors. That can cause resentment in others and sometimes a person will be punished for making decisions that contribute to good health management. Part of the Norwegian health system is in conflict with both good management and professionality. What some call fear culture has resulted in catastrophic decision making, , an example being when 2.9 million patient journals were outsourced to a company convicted of dishonesty, in a country without overall privacy laws. Nobody protested until the national broadcaster started to investigate.
Social responsibility can be regarded as part of virtue ethics; another key part is human rights.
Unfortunately, these are not highly regarded in Norwegian health and seldom mentioned even in discussions on health ethics. Instead, an economical evaluation of patients has been suggested. This is partly a break with Norwegian law (rule ethics), but also a break with population views (virtue ethics).
One downside of virtue ethics is that too much value can be placed on subjective views, and even quality can be overstressed. Some people work so hard that they exhaust themselves, or they ignore the fact that others may need help.
Since the three forms of ethics have advantages and disadvantages, professionalism is needed to balance different views.
One useful tool is utility ethics, where the utility or usefulness of an issue predominates. Health is basically useful. But if forced to choose, whom does one choose the utility for? During Coronavirus some countries chose to vaccinate old people first to avoid deaths. Other countries chose to vaccinate healthy people first to enable them better to help others.
Rule ethics is based on laws, guidelines etc. and is “always right” for certain types of conservative thinkers. But laws have can have difficulties in interpretation following the rapid development of both health and technology. And laws have problems with complexity, a key issue in our modern society.
Ethical controversies are prominent in health. At the same time ethics incorporate diversity, making clear goals and rules more difficult. Earlier Norwegian politicians argued for “more health for the money”, a view that is no longer popular. The People’s Health System is perhaps better, but how can the views of so many people be interpreted and communicated? At the very least we want a health system addressing our needs.
Virtue ethics and nursing ethics are a way of adjusting to this new view of the health system. Other professions should read and learn.