DONNIE J.

SELF

A STUDY

OF THE FOUNDATIONS

DECISION-MAKING

OF ETHICAL

OF NURSES

ABSTRACT. A study of nurses and nursing students was conducted to determine the
various philosophical positions they hold with respect to ethical decision-making in nursing
and their relationship to the subjective-objective controversy in value theory. The study
revealed that most nurses and nursing students tend to be subjectivists in value theory, i.e.,
believe that value judgments are purely personal, private expressions of one's own opinion
or inner-feelings and not believe that value judgments are knowledge claims capable of
being true or false and therefore not expressions of moral requirements and normative
imperatives emanating from an external value structure or moral order in the world. In
addition, the study revealed that most nurses and nursing students are inconsistent in the
philosophical foundations of their ethical decision-making, i.e., in decision-making regarding values they tend to hold beliefs which are incompatible with other beliefs they hold
about values.
Key words: Ethical decision-making, Subjective-objective Distinction, Consistency, Value
Theory, Nursing ethics

INTRODUCTION
The following study is an attempt to identify and understand better the
philosophical positions which nurses and nursing students, knowingly or
unknowingly, utilize in ethical decision-making in health c a r e ) Of special
interest are the various positions in the subjective-objective controversy in
value theory, i.e., whether value judgments are purely personal, private
expressions of one's own opinion and inner-subjective feelings or whether
value judgments are expressions of moral requirements and normative
imperatives emanating f r o m an external value structure or moral order in
the world. This will be elaborated in m o r e detail later.
The increase in interest in ethical decision-making in health care has
been dramatic during the past decade. However, very little empirical data
has been gathered on the issue. Usually those studies that have been
conducted simply report people's opinions on controversial issues such as
abortion, euthanasia, etc. Virtually no studies of actual data gathered on
the theoretical foundations of ethical decision-making have been reported.
This study was undertaken with the objective of identifying the philosophical stances of nurses with respect to ethical decision-making. The study
examines the following hypotheses:
(1) Most nurses tend to be objectivist in value theory, i.e., believe that
value judgments are knowledge claims capable of being true or false and
TheoreticalMedicine 8 (1987) 85--95.
1987 byD. ReidelPublishing Company.

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DONNIE J. SELF

are expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world.
(2) Most nurses are consistent in the philosophical foundations of their
ethical decision-making regardless of whichever position they tend to hold
on the subjective-objective issue in value theory.
The first hypothesis relates nursing to a fundamental issue in moral
philosophy -- namely, the theoretical status of values. Down through the
centuries value language has been analyzed in many ways. However, the
crucial issue in value theory comes in the subjective-objective controversy
because it is here that the theoretical status of values is determined.
Indeed E. M. Adams notes:
The thesis that value judgments in general and moral judgments in particular have no
objective ground, that they are subjective and private, needs to be thoroughly explored and
assessed. If it is a sound thesis, then we must face up to the consequences. If it is a false
thesis, we must look for ways to regain faith in the objectivity of values. Herein lies the
central task of moral philosophy of our age.2
The second hypothesis relates nursing to one of the most philosophically
desirable characteristics -- namely, consistency. Whatever position one
holds it must be internally consistent in order to be a logically viable
position and ought to be applied consistently to a wide range of circumstances. T h i s hypothesis contends that in decision-making about values
nurses tend to hold beliefs which are basically compatible with other
beliefs they hold about values.

METHOD
The study consisted of gathering, analyzing and interpreting data gathered
from questionnaires submitted to 912 nurses and 195 nursing students at
a major health care center in the United States. This included RNs, LPNs
and student nurses at various stages in their educational program. The
questionnaire consisted of one page containing 9 questions to be answered
affirmatively or negatively and several biographical designations. The
questions were constructed in such a way that there were three questions
relating to each of the three possible positions in the subjective-objective
issue (elaborated below in the Background Information section). The
questionnarie contained no controversial questions such as questions
which would elicit the respondent's feelings about issues of abortion,
euthanasisa, etc. Rather the study was designed to focus on theoretical
foundations of ethical decision-making in health care. However, the

ETHICAL DECISION-MAKING

OF N U R S E S

87

questions were carefully constructed in jargon-free language so as to

require no theoretical understanding of philosophical concepts such as
subjecfivism and objecfivism. Indeed the terms 'subjective' and 'objective'
did not even appear on the questionnaire. The questions were constructed
in pairs in order to check for consistency in the responses. For example,
questions one and eight were essentially the same question in different
words. The instrument was developed specifically for this study from a
similar instrument developed specifically for conducting a similar study
among physicians and medical students. These instruments had not been
utilized in any other study.

RESULTS

A total of 381 responses constituted a 34.4% return. The low percent

return is accounted for in part by the fact that the study was an eight-week
summer project with time constraints which did not permit follow-up
mailing, reminders, second or third questionnaires, etc, The surveyed
population consisted of 373 (97.9%) females and 8 (2.1%) males with an
age range from 17 to 65 years old. Classification of the respondents
indicated 41.2% RNs, 12.3% LPNs and 46.5% students. The religious
background of the surveyed population consisted of 70.0% Protestant,
16.9% Catholic, 2.4% Jewish and 10.7% others. The data gathered from
the questionnaires are shown in Tables 1 and 2. Table 3 presents the data
regarding the consistency of the responses. Analysis of the data requires
that both hypotheses be rejected as not true.

BACKGROUND

INFORMATION

A brief consideration of the subjective-objective issue in value theory

might be helpful in understanding the results of the survey. 3 All ethical
decisions are, implicitly or explicitly, based upon one of three possible
positions in value theory -- namely, complete subjectivism, partial subjectivism-partial objectivism, or complete objectivism. It is from these
positions that the subjective-objective controversy arises in ethics. This
issue has been extensively elaborated elsewhere with arguments for and
against the adequacy of the alternative positions. 4 Those arguments need
not be repeated. I will only summarize briefly a statement of the alternative positions here.
The three positions are determined by their stands on value experi-

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D O N N I E J. S E L F
TABLE 1
Nurse Decision-Making Data
Number of
Affirmative
Responses

Percentage

1. In difficult situations do you

generally seek the solution which
offers the greatest good for all
concerned -- patient, family,
medical staff, etc.

348

92.3%

29

7.7%

2. In medical decisions involving

ethical questions do you think
that there are right answers and
wrong answers?

158

41.8%

220

58.2%

3. Do you think that values such as

the rightness or wrongness of an
act are determined by the facts of
the context?

302

79.9%

76

20.1%

4. In complex medical ethical cases

can one sometimes have ethical
obligations without being aware
of them or realizing that they are
encumbent upon one?

357

94.7%

20

5.3%

5. Do you think that certain acts are

right and others wrong regardless
of the situation?

164

43.3%

215

56.7%

6. Do you think that rightness or

wrongness of an act is basically
determined by its consequences?

172

45.6%

205

54.4%

7. Do you think that in ethical

decision-making in medicine
values are relative to the person
making the judgment?

301

79.6%

77

20.4%

8. Do you always seek the best

welfare of the patient regardless
of what effect it has on the family,
medical staff or others?

180

48.3%

193

51.7%

9. Do you think that value judgements about medical ethical

situations can be either true or
false?

152

40.5%

223

59.5%

Questions

ence and value language. But first perhaps

Number of
Negative
Responses

Percentage

the distinction between

value

e x p e r i e n c e a n d v a l u e l a n g u a g e n e e d s t o b e c l a r i f i e d . V a l u e e x p e r i e n c e is
the affective-conative state that one experiences

or undergoes

when

in

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E T H I C A L D E C I S I O N - M A K I N G OF NURSES
TABLE 2
Biographical Data
Biographical
Characteristic

Percent of
Respondents

RN
LPN
Student Nurse
Male
Female
Protestant
Catholic
Jewish
Other

41.2
12.3
46.5
2.1
97.9
70.0
16.9
2.4
10.7

TABLE 3
Consistency Comparison

Question Number

Response Required
For Consistency

Actual
Response Received
Yes
No

Majority Actual
Responses

Pair

4
5

yes
yes

or

no
no

357
164

20
215

yes
no

Pair

2
9

yes
yes

or

no
no

158
152

220
233

no
no

Pair

3
7

yes
no

or

no
yes

302
301

76
77

yes
yes

Pair

5
6

yes
no

or

no
yes

164
172

215
205

no
no

Pair

1
8

yes
no

or

no
yes

348
180

29
193

yes
no

evaluative or e m o t i v e circumstances. I n contrast, value language is the

language or t e r m i n o l o g y u s e d to describe, report, or express value
experience. O n e c a n b e a subjectivist with regard to value e x p e r i e n c e a n d
still b e either a subjectivist or a n objectivist with regard to value language.
O n o n e e x t r e m e is what is k n o w n as p u r e or c o m p l e t e subjectivism.
Existentialism is the m o s t p o p u l a r p a r a d i g m of this position. Subjectivism
is subjective with respect to b o t h value e x p e r i e n c e a n d value language. It
holds that value e x p e r i e n c e is n o t cognitive, n o t epistemic or k n o w l e d g e yielding, a n d n o t the d i s c e r n m e n t of a value structure in reality. B u t also,

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DONNIE J. SELF

value language as distinct from value experience is held to be subjective in

that value judgments are held to make no truth claim at all, and so cannot
be true or false. Pure subjectivism maintains that moral judgments are
expressions of emotions, preferences, or decisions and are not cognitively
significant; i.e., they literally do not make a knowledge claim. Value
judgments are not even of or about value experience. They are merely
expressions of emotions Or preferences.
A middle position is partially subjective and partially objective. It is
subjective with respect to value experience only. It is objective with
respect to value language. Utilitarianism is the most widely known
paradigm of this position. The middle position holds that value judgments
are of and about value experience in a cognitively significant manner such
that they do make knowledge claims which can be confirmed to be true or
false. Value language serves a definite function. It makes truth claims
about value experience and expresses and describes value experience. Yet
it does not express the semantic or meaning content of value experience
for this middle position denies that value experience has a semantic
content. Value language is not grounded to the world through experience
because value experience itself is subjective and not a discernment of an
external objective value structure or moral order in the world. It has no
semantic connections with the structure of reality. Value language can be
reduced to or translated into non-value language, i.e., to factual language
in terms of the descriptive-explanatory language of natural science. This is
usually done in terms of the the language of psychology such that value
judgments become empirically verifiable by observation of behavior. Thus,
utilitarianism, a paradigm of this position, reduces value judgments to
judgments of utility which are ultimately explicated in terms of the
production of pleasure and avoidance of pain and therefore is subjectivistic with respect to value experience, but yet objectivistic with respect
to value language.
Lastly, pure objectivism is the exact opposite of pure subjectivism. It is
objectivistic with respect to both value experience and value language.
Objectivism in value theory is the belief that values are expressions of
moral requirements and normative imperatives emanating from an external value structure or moral order in the world. To be objective simply
means being independent of experience. Objective reality is held to exist
independently of one's experience of it or one's thoughts and feeling about
it. Similarly objectivism in value theory holds that value requirements and
normative imperatives exist independently of one's experience of them or
one's thoughts and feelings about them. Emotive repulsion to cruelty such
as in child abuse would be an example of an objective normative impera-

ETHICAL DECISION-MAKING OF NURSES

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tive which exists independently of how one feels about it. Indeed those
persons who are not repulsed by such cruelty are considered sick and in
need of help. The formal ethics of Immanuel Kant and the Judeo-Chrisfian
ethics of the Old and New Testaments are the best known paradigms of
objectivism. Objectivism holds that value judgments are objective in that
they are cognitively significant and make a knowledge claim which can be
confirmed to be true or false. They embody a significant semantic claim.
The content of value judgments is not dependent upon the peculiarities of
the agent but is determinable by any rational observer appraised of the
relevant facts. Pure objectivism maintains that value language is not
reducible to non-value language since value experience discerns a dimension of reality not discernable through any other mode of experience.
Value judgments are not merely expressions of emotions or attempts t o
evoke similar attitudes in others, but rather are of and about an external
value structure or moral order of the world. Values exist independently of
a discerning mind, and there are norms or value requirements regardless
of whether or not anyone is aware of them. Like necessary connections,
value requirements are not dependent upon knowledge of them. Value
language is of and about these value requirements and normative imperatives in reality. Value language is expressive of this value experience, i.e., it
translates into language what is semantically present and felt in value
experience. It relates a dimension of experience which is not expressible
through any other language. Value language is not reducible or translatable into any other language such as factual language. No other kind of
language can express the content expressed in an ordinary value judgment.
The dimension of reality discerned through value experience cannot be
discerned through any other mode of experience.

DISCUSSION
With the above understanding of the subjective-objective distinction in
value theory, the data collected from the questionnaries can be interpreted
more clearly. Analysis of the data requires that hypothesis number i be
rejected and shows that it is not true that most nurses tend to be
objectivist in value theory, i.e., believe that value judgments are knowledge
claims capable of being true or false and are expressions of moral
requirements and normative imperatives emanating from an external value
structure or moral order in the world. This conclusion tends to support
the notion that our culture has become increasingly subjectivistic with respect to values. Since the turn of the century there has been a tremendous

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D O N N I E J. S E L F

increase in the popularity of subjectivism as expressed in existentialist

thought such as the writings of Albert Camus, Jean-Paul Sartre, etc. This
conclusion is supported by the following evidence. When given six
opportunities to support the objectivist position, by answering affirmatively to questions number 2, 3, 4, 5 and 9 and negatively to question
number 7, the majority of nurses supported the objectivist position in only
two of the six opportunities. For example, an affirmative response to
question number 2 regarding the possibility of right and wrong answers to
ethical questions requires that value judgments in general and ethical
judgments in particular be cognitive or knowledge-yielding in character -a requirement essential to the objectivist position. Yet a minority of the
respondents (41.8%) answered question number 2 affirmatively.
Conversely, when given six opportunities to support the subjectivist
position, by answering affirmatively to question number 7 and negatively
to questions number 2, 3, 4, 5 and 9, the majority of nurses supported the
subjectivist position in four of the six opportunities. For example, strong
support for subjectivism was found in the response to question number 7
regarding values being relative to the person making the judgment where
an affirmative response (79.6%) would be philosophically required by the
subjectivist position. Essentially eight out of every ten nurses responded
that values are relative to the person making the judgment and not
determined by objective, external facts. This point which is frequently
misunderstood has been elaborated in more detail elsewhere.5 Additional
support for subjectivism was found in the response to question number 9
regarding the possibility of value judgments being either true or false
where a negative response (59.5%) would be required for support.
The responses to the three questions relating to the middle position,
such as utilitarianism, (numbers 1, 6 and 8) which is partially subjective
and partially objective indicated that nurses are basically not utilitarian in
ethical decision-making. For example, the negative response to question
number 6 (54.4%) regarding the rightness and wrongness of an act being
determined by its consequences, which is absolutely essential to utilitarianism, indicates that most nurses are basically not utilitarian in their
philosophical stance to ethical decision-making. However, the overwhelming positive response to question number 1 (92.3%) regarding the greatest
good for the greatest number shows that when consequences are considered nurses are pluralistic utilitarians with mnitiple foci of concern.
Moreover the negative response to question number 8 (51.7%) regarding
always seeking the best welfare of the patient corroborates this by
indicating that the majority of nurses are not monistic utilitarians with a
singular concern. That is, with regard to the perceived morality or

ETHICAL DECISION-MAKING OF NURSES

93

rightness of their acts, nurses take many factors into consideration and not
just the usefulness of their act in terms of one pre-eminent factor -- not
even the welfare of the patient solely.
Further, analysis of the data requires that hypothesis number 2 be
rejected and shows that most nurses are inconsistent in the philosophical
foundations of their ethical decision-making regardless of whichever
position they tend to hold on the subjective-objective issue in value theory.
This is to say that nurses simultaneously hold some subjective beliefs and
some objective beliefs about values which are philosophically incompatible with each other. A similar finding in a study of physicians was
reported earlier as referenced in footnote 1. This conclusion was demonstrated by pairing related questions and comparing the actual responses of
the nurses to the responses required for consistency.
Table 3 shows the question pairings, the responses required for consistency, and the actual responses received. In three of the five question
pairs the responses received differed from the theoretically consistent
pattern. For example, with questions 4 and 5, which would require two
affirmative responses or two negative responses for consistency, the actual
response received was a majority of affirmative responses to question 4
and a majority of negative responses to question 5.
Additional evidence from the data which supports the contention
that hypothesis number 2 is false is found in analyzing the responses
to questions number 3 and 7. An affirmative response to both of these
questions simultaneously is contradictory. Yet essentially eight out of
every ten nurses responded affirmatively to question number 3 (79.9%)
and affirmatively to question number 7 (79.6%) at the same time. Perhaps
this is not too surprising since it was noted earlier that the distinction
between values being relative to the person making the judgment versus
being relative to the facts of the circumstances is often not well understood.
Finally inconsistency can also be observed by analyzing the responses
to question number 4 regarding the existence of ethical obligations
independent of knowledge of them -- an essential feature of objectivism.
The large affirmative response to question number 4 (94.7%) requires that
values exist independently of a discerning mind and that there are
normative imperatives or value requirements in reality which reflect the
existence of a normative structure or moral order in the world. But the
existence of such a moral order or of ethical obligations independently of
knowledge of them is philosophically inconsistent with the subjectivist
position noted earlier to be endorsed in various ways by the responses of
the nurses. From all this one can conclude that when the group is viewed
as a whole, nurses are inconsistent in the philosophical foundations of

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D O N N I E J. S E L F

their ethical decision-making. This is not to say that they are any more
or less inconsistent than any other group or profession. But even if
inconsistency in ethical decision-making is universal, it is still undesirable.

CONCLUSION

The rejection of hypothesis 2 is not to say that nurses are inconsistent in

their actual ethical decisions in health care (although one would suspect
this if their philosophical foundations are inconsistent) but only that the
responses they give to questions about how ethical questions in health care
are to be determined, require inconsistent philosophical stances in value
theory. Thus one should be careful not to confuse ethical decisions in
health care with questions about ethical decision-making in health care,
i.e., with the methodology for determining the response to an ethical
question in health care. Basically the difference is in asking what to do as
opposed to asking how to determine what to do. Ethical questions in
health care are 'what' questions. Methodological questions about ethical
decision-making in health care are 'how' questions. For example, the
question of whether or not to turn off the respirator on a particular
terminal patient is an ethical question in health care management, but
determining the grounds for turning off respirators, whether it be for the
welfare of the patient or the welfare of all concerned, is a philosophical
question about the methodology for determining ethical decisions in
health care. It might be noted here that none of the questions on the
questionnaire are ethical questions about health care, rather they are
questions about the various philosophical stances which determine the
methodology for ethical decision-making in health care. Perhaps ethical
questions in health care would not seem so difficult if the philosophical
questions could be agreed upon.
Since conceptual clarification and consistency in logical reasoning are
major aims of philosophy, an increase in exposure to philosophical
considerations in nursing would no doubt give nurses a better understanding of the philosophical foundations of ethical decision-making in health
care.
D O N N I E J. S E L F

Department of Humanities in Medicine,

College of Medicine,
Texas A &M University,
College Station, TX 77843, U.S.A.

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NOTES
1 A similar study of physicians and medical students is reported on pages 5 7 - 6 9 of the
February 1983 issue of Theoretical Medicine.
z For the context of this remark see E. M. Adams 11].
3 This brief description of the alternative positions in the subjective-objective distinction
comes from the similar study of physicians and medical students reported on pages
57--69 of the February 1983 issue of Theoretical Medicine.
4 For an extensive elaboration of the positions in the subjective-objective distinction and
the arguments for and against each position see D. J. Self [2, 3, 4, 5].
5 The point of values being relative to the person making the judgment versus values
being relative to the facts of the circumstances is often not well understood. This issue
is addressed in D. J. Self [3].

REFERENCES
[1]
[2]
[3]
[4]
[5]

Adams, E. M., 'The Grounds of Ethics', Department of Philosophy, University of

North Carolina, Chapel Hill, (n.d.), p. 6
Self, D. J., 'Inconsistent Presuppositions of Dewey's Pragmatism', The Journal of
Educational Though 10, (1976) 103-104.
Self, D. J., 'Methodological Considerations for Medical Ethics', Science, Medicine and
Man 1, (1974) 201.
Self, D. J., 'Philosophical Foundations of Various Approaches to Medical Ethical
Decision-Making', The Journal of Medicine and Philosophy 4, (1979) 20-31,
Self, D. J., Value Language and Objectivity: An Analysis in Philosophical Ethics,
Doctoral Dissertation, University of North Carolina, Chapel Hill, 1973.