A FUNDAMENTAL ETHICAL

APPROACH TO NURSING: SOME

PROPOSALS FOR ETHICS EDUCATION

Chris Gastmans

Key words: ethics education; ethics of care; moral perception; moral sensitivity; nurse–
patient relationship; nursing; nursing ethics; virtue ethics

The purpose of this article is to explore a fundamental ethical approach to nursing and
to suggest some proposals, based on this approach, for nursing ethics education. The
major point is that the kind of nursing ethics education that is given reflects the theory
that is held of nursing. Three components of a fundamental ethical view on nursing are
analysed more deeply: (1) nursing considered as moral practice; (2) the intersubjective
character of nursing; and (3) moral perception. It is argued that the fundamental ethical
view on nursing goes together with a virtue ethics approach. Suggestions are made for
the ethics education of nurses. In particular, three implications are considered: (1) an
attitude versus action-orientated ethics education; (2) an integral versus rationalistic ethics
education; and (3) a contextual model of ethics education. It will also be shown that the
European philosophical background offers some original ideas for this endeavour.

Introduction
Ethics is taking an increasingly prominent place in nursing education.1–3 It has
been generally accepted that nurses are confronted with unique nursing ethical
problems that arise from their involvement in patient care. Specific nursing ethics
consultations (e.g. ethics rounds) have been implemented in some health care
institutions to discuss these issues.4,5 Besides the specific nursing (intradiscipli-
nary) ethical dialogue, nurses have an increasingly greater role to play in the inter-
disciplinary ethics consultations that are being implemented in many health care
institutions.6–8 In most countries, ethics rounds and ethics committees are
probably the most important channels through which intra- and interdisciplinary
ethics consultations take place at local and national levels. A true intra- and inter-
disciplinary ethical debate can take place only if all those involved, in all the
relevant professions, participate with the requisite (also ethical) knowledge.

Address for correspondence: Chris Gastmans, Associate Professor, Center for Biomedical Ethics
and Law, Faculty of Medicine, Catholic University of Leuven, Kapucijnenvoer 35, 3000 Leuven,
Belgium. E-mail: Chris.Gastmans@med.kuleuven.ac.be

Nursing Ethics 2002 9 (5) © 2002 Arnold 10.1191/0969733002ne539oa

 A fundamental ethical approach to nursing 495
Against this background, the participation of the nursing profession in ethical
dialogue already constitutes an important reason to provide nurses with an edu-
cational grounding in ethics.
This article is primarily focused on the kind of basic ethics education all nurses
should receive if they are to provide ‘good care’. Owing to the double focus on
ethics and nursing, a dialogue between nursing models and theories of ethics
will be developed throughout the whole length of the article, which has two aims.
The first aim is to sketch broad outlines for a foundational ethical view on nursing,
within which fundamental reflection about basic ethics education for nurses can
take place. Special attention will be given to the intersubjective character of
nursing and the role of ethical sensitivity in nursing practice. The second aim is
to present some theoretical proposals for the ethics education of nurses. Attention
will also be paid to some aspects of an integral and contextual model of ethics
education. The exploration of the practical consequences of applying this
approach to nursing practice do not fall within the scope of this article.

A fundamental ethical view on nursing

The development of a view on nursing ethics education requires a consensus
regarding what nursing practice means. The kind of nursing ethics education that
is given depends on the theory that is held of nursing. What is the essence of
nursing? In this article, the view of nursing held is based on some thoughts of
Anne Bishop and John Scudder, according to whom nursing can be defined as an
‘ethical practice based on the ethical requirement to promote the well-being of the
patient by caring for him or her by a personal relationship’ (p. 104). 9 The fact that
I base my view of nursing on the ideas of Bishop and Scudder implies some
limitations in the scope of my analysis. These authors set the personal
nurse–patient relationship at the heart of nursing. Following this relational per-
spective on nursing, the caring relationship is described in this contribution as a
foundational condition of nursing practice. As a consequence, I do not deal with
nursing practice that does not involve direct patient contact. Nevertheless, this
domain of nursing practice also has a moral significance, as it too is based on the
moral requirement of promoting the well-being of the patient.
The first section deals with the characterization of nursing as an ethical practice.
Thereafter, two components of the ethical practice of nursing (i.e. the intersub-
jective character of nursing practice on the one hand, and moral perception on
the other) will be examined more closely.

Nursing considered as ethical practice

The fact that a firm ethics education for nurses is considered to be important
supports the claim that providing care is an ethically laden practice. Alasdair
MacIntyre defines practice as ‘any coherent and complex form of socially estab-
lished cooperative human activity through which goods internal to that form of
activity are realized’ (pp. 187–88).10 In the performance of these activities one tries
to achieve those standards of excellence that are appropriate to that form of
activity.10

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When MacIntyre’s concept of practice is applied to nursing, nursing can be
defined as ‘the totality of skills and attitudes (caring behaviour) that are applied
in the context of a particular caring relationship, with the intention of providing
‘‘good care’’ (the goal) to the (usually sick) fellow person’ (p. 45).11 To describe
the content of the practice of nursing, it is not at all sufficient to restrict oneself
to enumerating a few technical nursing functions and skills, such as, for example,
the diagnostic function and administering and monitoring therapeutic interven-
tions and regimens. In addition to the technically manageable nursing functions
(clinical competence), Patricia Benner12 cites others that require something apart
from a purely technical approach. These would include, among other things, pro-
viding comfort and preserving human dignity in the face of pain and extreme
breakdown, presencing (being with the patient), and providing comfort and com-
munication through touch. These functions require the ability to be sensitive to
and engage with another human being in a situation of vulnerability, stress or
distress.13
Noteworthy in this definition is the goal-orientated character of nursing
practice. Whatever nurses do must always be related to the final goal that is set.
Generally, the goal of nursing activity is described as the promotion of the
well-being of the patient by providing good care in the wider meaning of the
word (i.e. on the physical as well as the psychological, relational, social, moral
and spiritual levels 11). Nurses participate in an ethical practice. In each particu-
lar situation, they have to make personal choices and decisions based on the good
that nursing practice sets as a goal. This ethical practice becomes concrete through
the personal relationship between the nurse and the patient. 9 The quality of
nursing care must always be seen in the light of the relationship between a unique
nurse and a unique patient. The patient cannot be considered as a passive object
to which a care strategy is to be applied. On the contrary, caring activities pre-
suppose a reciprocal interaction between human persons who enter into rela-
tionships with each other based on their uniqueness.
To describe some proposals for the ethics education of nurses, a thorough
analysis of two basic concepts, which up to now have remained implicit in the
discussion, has to be given. In the following section, the intersubjective character
of the view of persons and care on which this view of nursing is based will be
analysed, then the concept of ‘moral perception’ will be clarified.

The intersubjective character of nursing

An important fact connected with nursing considered as ethical practice is the
intersubjective context in which nursing care must be situated. By providing care,
and the attitudes and skills associated with this activity, the nurse enters as a
person into a relationship with the patient. Nel Noddings remarks that the essen-
tial characteristics and the quality of the care phenomena are linked with the rela-
tionship between the one who is caring and the one who is cared for.14 In many
cases one speaks of a reciprocal relationship (i.e. both the one who is caring and
the one who is cared for actively participate in the care activity in some respect).
The fundamental reciprocity of a relationship of care can be found in the dynamic
interaction of giving care and receiving care.
A view of nursing in which the relationship between nurse and patient is

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 A fundamental ethical approach to nursing 497
regarded as central presupposes an intersubjective view of human beings,
within which interpersonal relations are interpreted in terms of solidarity
and responsibility. In Europe, the intersubjective view of human beings is
exhaustively described in the framework of the personalistic tradition in
ethics.15,16
As early as 1923, the Jewish philosopher Martin Buber wrote his pioneering
work on being human, Ich und Du (I and Thou).17 With this most valuable contri-
bution, a new insight broke through: one can never be a human being alone.
Humans essentially stand in an open relationship, involved with the reality in
which they live and with other humans to whom they owe their existence and
who continue to surround them.
There has been a new contribution to the view of humans as intersubjective
beings from a totally different perspective, namely the ethics of care.18,19 Care ethi-
cists give a lot of attention to the anthropology that underlies ethical thinking in
health care. Carol Gilligan writes that: ‘The most basic questions about human
living – how to live and what to do – are fundamentally questions about human
relations, because people’s lives are deeply connected, psychologically, economi-
cally, and politically’ (p. XIV).19
In contrast to more individualistic views of people and community, care ethi-
cists opt for a perspective according to which all individuals find themselves in
a complex network of relationships that are often not the product of their own
personal choices.20 One person always holds something of the lives of others in
his or her own hands, or has the lives of others temporarily placed in his or her
hands. Every day, always with new variations, people are dependent on others
and others are dependent on them. In short, everyday interaction between persons
is a complicated network of mutual dependencies. In an intersubjective view of
human beings, vulnerable dependency and self-sufficient autonomy are regarded
as equally valuable and interwoven aspects of human life. Annelies van Heijst
expresses interdependency as a human characteristic when she claims that ‘people
are people’s concern’.21
This brief sketch of the intersubjective view of human beings that underwrites
the practice of nursing implies that one should focus attention on nurses them-
selves. They are also part of an interpersonal network of people around them.
Caregiving is a concrete form of interpersonal relationship. The care relationship
is more than a technical relationship; it is an interpersonal interaction where the
technical aspect of care rests on the successes and failures, and the open oppor-
tunities and vulnerable situation of nurses as persons.22 In the following section,
‘the nurse as person’ will be considered with the aid of the concept ‘moral
perception’.

‘Moral perception’ and ‘the nurse as person’

Moral perception situates itself in the first phase of the caring process, as
described by Joan Tronto.18 During this exploratory phase, a caring person is
‘morally sensitive’ to his or her surroundings. He or she is attentive to what
happens around him or her and tries to detect situations where the life-sustain-
ing web containing the others is weakened. Using this morally sensitive attitude
(moral sensitivity) a caring person clears the path in order ‘to be touched by’ and

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subsequently ‘to be concerned by’ the situation of the other who is in need of
care.
According to the American philosopher, Laurence Blum, a sensitive moral per-
ception determines to a large extent what from an ethical perspective is relevant
to observe and think.23 In this way, an accurate perception of the ethical compo-
nents of a specific situation wherein a person is embedded is a necessary condi-
tion to ensure an adequate clarification of the situation of the other. According to
Blum, a sensitive moral perception is characterized by the capacity of the agent
to interpret the concrete situation of the other in terms of the other’s well-being.
For example, one can interpret the situation of a woman who does not have a
place to sit on a bus as: ‘A woman carrying a shopping bag is standing in the
bus.’ This neutral perception in itself does not motivate the moral agent to
perform altruistic actions. What is perceived is experienced as morally irrelevant.
The situation changes dramatically when one redescribes the same woman as
follows: ‘An old woman has no place to sit on the bus, and is therefore forced to
stand and carry her heavy shopping bag.’ The latter description – in contrast to
the first – allows for an interpretation of the situation of the woman in terms of
her well-being. The misfortune of the woman is an essential part of the descrip-
tion of her situation. This morally relevant perception of the woman’s particular
circumstances includes a motivation necessary for altruistic conduct.24
In Blum’s analysis of moral perception, attention to the particular is considered
especially important. A discerning insight into a particular situation should put
the agent in a position to tell which ethically relevant factors are present.25
Sensitivity to the particularity of every situation cannot be detached from our
knowledge of ethical principles and norms. On the contrary, the right application
of ethical principles and norms in concrete situations presupposes precisely the
capacity to be attentive to the ethical features inherent in a particular context.
Moral perception is a capacity that should be associated not only with the intel-
lect but also with the moral person in his or her totality. Diverse aspects of the
agent’s ethical personality are called into play when he or she perceives, inter-
prets and responds to the morally relevant reality.24 These aspects include, among
others: the person’s implicit, intuitive moral ideas (about quality of life, suffering,
death, human dignity); his or her emotional, relational and communicative abil-
ities (empathy, emotional intelligence); his or her personality traits (altruistic,
introverted); and his or her moral background (personal set of values, ethics edu-
cation, experience with ethical dilemmas).
From the perspective of nursing ethics education, Blum’s view of the agent
who exercises moral perception is of special interest. Not the human intellect or
any other more or less distinct human capacity, but the whole person of the
nurse as an ethical subject perceives and interprets his or her surrounding world
from an ethical standpoint. The nurse, with his or her psychological and moral
repertoire, takes in what is going on in the surrounding world, identifies the
ethically relevant aspects, and tries to form an attitude (whether supported by
concrete actions or not) that realizes the inherent ethical possibilities of the
particular situation to the greatest possible extent. This whole process requires the
ability to cultivate a deep sensitivity for what is ethically significant in a partic-
ular situation, and then to act appropriately in accordance with that percep-
tion.26,27 This is not a matter of gaining an intellectual understanding, but a sort

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 A fundamental ethical approach to nursing 499
of ethical know-how, or a sense of what behaviour is most appropriate in a given
situation.

A virtue ethics approach

The fundamental ethical view on nursing, which has been presented in the
previous sections of this article, reflects a so-called virtue ethics approach.10,28 An
ethics of virtue differs from Kantian and utilitarian approaches to ethics primar-
ily in terms on its distinct emphasis on the primacy of good character over right
conduct. (The virtue ethics approach argued in this article is not intended to
replace exclusively other approaches to ethical conduct. It would be very inter-
esting to analyse in greater depth the supposed opposition between the ethics of
virtue and Kantian and utilitarian approaches to ethics. Perhaps the opposition is
less sharp than is sometimes thought. This fundamental analysis did not fall
within the scope of this article.)
Virtue ethics can be defined as a systematic and coherent account of
virtues. Virtues can be characterized as acquired human qualities (character
traits, attitudes) that are for some important reason desirable or worth having.29
Virtues allow the attainment of a good that is inherent in a particular practice. 10
It would be the aim of a virtue ethics approach to identify certain traits as
desirable, to analyse and classify such traits, and to explain their moral signifi-
cance.30
According to a virtue ethics approach, questions about the quality or the nature
of the ethical agent do not come after questions concerning morally correct
actions. On the contrary, the question of what qualities a person must have in
order to be ethically good is considered as the primary factor, because the
ethical quality of actions is largely determined by the ethical qualities of the
agents whose actions they are.31 For example, the ethical quality of a caring
attitude, which issues from an adequate moral perception of a particular care sit-
uation, should not be measured only by the value of the concrete actions per-
formed. It is precisely the other way around: particular care actions acquire their
ethical value in the light of the quality of the caring attitude of which they are
the expression. In a comparable manner, the professional goodness of a nurse is
not simply a question of acting according to professional standards. A good nurse
is one who, through practice, has learned to put both heart and soul into the
job, and to do as a matter of course what is expected of a good nurse: to be con-
cerned about the well-being of patients; and to be expert, honest, fair, cordial,
reliable and more, and all at the right time, towards the right person, and so
forth.32
The concept of virtue has a long tradition in ethical theory. Yet it was almost
considered suspicious, particularly in the experienced morality of the twentieth
century. Since modern times, virtue has no longer formed the indisputable centre
of ethics and has been considered as an important issue by fewer and fewer
authors.33 Robert Louden states that if one limits oneself to evaluate agents rather
than acts, the theory will fail34: (1) to provide guidance for finding the way out
of practical moral quandaries; (2) to make sense of cases in which good people
do harmful actions; (3) to allow one to make the list of specific acts that for social

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reasons must be absolutely prohibited; and (4) to provide the way to notice when
good persons have become bad, because we have nothing but the person’s actual
character to utilize.
Recently, more authors have become convinced of the advantages of a virtue
ethics approach.10,35,36 The uneasiness with regard to other important positions
(Kantian and utilitarian) in the ethics of our times is clearly explained in three
points in a recent study on the rehabilitation of virtue ethics.37
First, Wybo-Jan Dondorp37 claims that, by restricting ethics to the rules gov-
erning society (in other words the way in which people live together), personal
ambitions, character building, the ethical quality of the person, etc. remain beyond
the scope of ethics. Virtue ethics concentrates precisely on these things.
Secondly, according to Dondorp,37 a great deal of present-day ethics is ratio-
nalistic as far as its notion of ethical judgement is concerned. Understanding
ethical judgement as the application of general rules and principles to concrete,
real-life situations wrongly ignores ethical sensibility as well as the receiving and
creative sides of ethical experience. Virtue is precisely the ability to perceive the
ethically relevant qualities of a situation (moral perception), judge them ade-
quately and, on that basis, take the right decision.
Thirdly, Dondorp37 states that a great deal of present-day ethics is rather deon-
tological. By speaking of ethics in terms of what should be done, the link becomes
lost between the obligation to do something, the good that is the ultimate goal,
and the motivation to act. Virtue is the concretely situated orientation towards
the good that comes from within to such an extent that it is put into practice.
In conclusion, one could say that there is no homogeneous version of virtue
ethics, and that the revival of virtue ethics over recent decades offers a variety of
theories that apparently seem united by their opposition to various strands of
Kantian and utilitarian ethical theories. However, in view of the threefold uneasi-
ness mentioned above, a virtue ethics approach appears to do more justice to the
fundamental ethical view on nursing, which has been explained in this article. If
this is so, virtue ethics could be regarded as offering more promising perspectives
than other ethical approaches to the ethics education of nurses.1

Some proposals for nursing ethics education

What can be concluded concerning nursing ethics education from these theoreti-
cal considerations about the essence of nursing and the status of virtue ethics?
First of all, the primary goal of nursing ethics education can be derived from the
internal aim of nursing and therefore should be defined as learning how to
promote the well-being of patients. What kinds of knowledge and which practi-
cal, affective, communicative and reasoning skills do students have to learn in
order to reach this goal? Inspired by this question, three important dimensions
can be distinguished around which the development of nursing ethics education
can be orientated: an attitude- versus an action-focused ethics education; an
integral versus a rationalistic ethics education; and a contextual ethics education.

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 A fundamental ethical approach to nursing 501

An attitude- versus an action-focused ethics education

According to a virtue ethics approach to nursing ethics education, the funda-
mental goals are: the transformation of the ethical agent; the orientation of his or
her life; and the cultivation of virtuous attitudes and character, or excellence in
his or her activity.1,38 Virtue is the condition that makes this possible: the acquired
ability to adopt the correct position and to do the right thing in changing situa-
tions of life. These actions are not the core but rather the effects of what deter-
mines ethical quality in the most profound manner. Actions are not just called
right or wrong, but someone is praised because of his or her courage, friendli-
ness, honesty, loyalty, etc., in other words, because of attitudes or character traits
that are more durable than just one simple action.32 It should be the crucial task
of ethics education to show the ways in which personal and professional life
stands to be enriched or enhanced by the possession of such virtuous qualities
and attitudes. With such a view, ethics education is more a matter of the cultiva-
tion of such virtuous excellences, bringing ethical agents to an appreciation of the
worthwhileness of ethical and other enterprises for their own sakes, than of
training in obligations or the imposition of prohibitions.13,30
The argument in favour of the cultivation of virtuous attitudes can be connected
with the importance of the caring presence in everyday professional practice. 39
The ethical value of a caring presence with the other must be connected with an
ethically qualified attitude that manifests a deep respect for the value of the other.
The Dutch philosopher Paul van Tongeren speaks in this connection of the culti-
vation of an attitude of ethical sensitivity in regard to everything we encounter.
By this he intends to relativize the importance of ethical ‘activity’ in the interest
of promoting an ethical attitude informed by ethical virtues, which is sensitive to
the ethical possibilities and unarticulated intimations of the good embedded in
every particular context.40 According to van Tongeren, this means being sensitive
to the ethical value that is inherent in persons, relationships and experiences.
According to Scott, raising awareness of the moral dimension of practice and
supporting the development of moral sensitivity is one of the key reasons for
teaching ethics to nurses.1,13
This somewhat abstract explanation can be clarified with an example of a nurse
who ‘treats’ his or her patient in a caring way. The concrete caregiving actions
that the nurse performs are the expression of a virtuous attitude that has been
acquired as a response to the understanding of the ethical value of the patient as
a human being on the one hand, and the understanding of caring as ethical virtue
on the other. The ethical significance of the patient and caring is not merely passed
down to the nurse as part of general knowledge. It is rather an insight into what
good care is, which is acquired in concrete contexts. The nurse can respond to the
patient’s need for care in a justified manner only if he or she has been attentive
to the ethical significance revealed by the patient and the particular context in
which the patient finds himself or herself. In other words, by cultivating an
attitude of ethical sensitivity, the nurse teaches himself or herself to be receptive
to the ethical possibilities that are inherent in every particular context of care.41
On the basis of the ‘insight’ acquired through this process, the nurse tries to find
an appropriate response to the patient’s situation.
It is clear from this plea for the cultivation of ethical attitudes that the ethical

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vocabulary normally used in ethics education has to be broadened. Along with

rationalistic ethical concepts (ethical principles, ethical judgements, ethical
methods of analysis, etc.), others such as character, virtues, intuition, personality,
emotions, moral perception, moral sensitivity and so on, must be a conspicuous
feature of the educational package. According to Scott, concepts such as moral
sensitivity and moral perception could be linked to that which nursing students
already know and are familiar with, namely ‘the importance of observing their
patients, of looking and seeing, and forming a clinical judgement on the basis of
their perceptions’ (p. 129).13 This connection with clinical practice could make
ethics more real and more important for nursing students.

An integral versus a rationalistic ethics education

The integral character of ethics education means that rational argumentation,
emotional involvement and contextual factors should never be completely sepa-
rated from one another.42 The integrating factors of ethical conduct are not only
the cognitive factors, but also the affective and motivating factors: the capacity to
imitate the good that attracts, the capacity to empathize with the other, which
brings emotional solidarity, among other things.38 Virtue education is, in no small
part, education of the emotions. To teach virtue requires that we take seriously
the idea that we can become (to a greater degree than we often imagine) ‘agents’
of our emotional lives.43 Virtue ethics regards ethical development as a matter of
crucial interplay between the different dimensions of human being (rationality,
emotions, etc.) and it has been of concern to give a coherent account of this inter-
play.30 However, there is still an enormous amount of conceptual work to be done
on the psychology of virtue, in order to reach a clearer understanding of the har-
monization of reason, affect and behaviour in virtuous conduct, as well as, from
an ethics educational viewpoint, what might constitute appropriate and effective
ethics educational strategies for the promotion of such conduct.44
When applied to nurse education, the integral view implies that human actions
cannot be regarded as a mere summation of rational and emotional components.
When a nurse acts, he or she acts as a totality, using both rational and emotional
capacities. 45 The emotional faculties of nurses should be cultivated, because they
play a double role in the process of ethics deliberation. First, emotions have an
important role to play in the detection of ethical problems in nursing.
Experiencing certain emotions is a vital part of broadening one’s perspectives and
deepening one’s understanding of certain aspects of the human condition.13
Emotions can be considered as modes of attention enabling nurses to notice what
is morally salient, important, or urgent in themselves and their surroundings.
They help nurses to track the morally relevant ‘news’. They are a medium by
which nurses discern the particulars. 43 For example, gross neglect of elderly
people provokes feelings of repulsion or horror in nurses. It is precisely that intu-
itive sense that motivates them to formulate an ethical problem concerning this
neglect. They then obviously bring that feeling into the discussion and clarify its
meaning. An affective involvement with the well-being of patients prevents
‘blindness’ and ‘hard-heartedness’, latent mechanisms that can make nurses insen-
sitive to the human side of caregiving.
Secondly, emotions have an expressive function; the quality of ethical actions

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does not depend only on the content of the action, but equally on the way in
which the action is performed.24,46 The manner in which one person approaches
another shows a certain ‘colour’. Who we are and what we hold as important are
reflected in our emotional communication. The presence or absence of certain
emotions can be morally significant. To take one example, a helping action that
is emotionally flat may not be received in the same way as an action conveyed
through a more positive, affective expression. As recipients, we may judge that it
lacks what is important for our well-being: namely, that others be engaged with
us here and now and that they view that kind of attention and engagement as
important in itself.43
Besides education of nurses as persons, emotional involvement, imagination
and the cultivation of virtuous attitudes require attention to the context in which
an individual has to try to exercise these qualities in practice.24 This leads to the
contextual character of ethics education.

A contextual ethics education

Virtuous attitudes do not occur in a vacuum. They are embodied by a particular
nurse who is a member of many groups and communities. The relational, cultural,
social, institutional, political and religious links that the nurse forges with others
form the context in which the attitudes of ethical life come into being and are
experienced. 47,48 The ethical character formation of nurses can best be regarded
as a practical educational event that gradually takes shape within specific narra-
tive communities, of which health care institutions are a clear example. In this
section, these points will be illustrated by examining the influence of the institu-
tional context (health care institution) on the rise and development of ethical atti-
tudes, in particular the attitude of caring.
At the beginning of this article, it was argued that the intersubjective context
in which care is provided is an intrinsic part of the care situation. Through care,
the nurse as a person enters into a relationship with the patient. However, there
is not only the nurse–patient relationship. The care process itself usually takes
place within the context of the co-ordinated activities of a team of caregivers
(physicians, nurses, social workers, etc.) who are also part of a health care insti-
tution (hospital, nursing home).38 The institutional context of the health care insti-
tution is partially outlined in the (non)existence of clear ethical opinions and
policies about care, the (non)existence of structured interdisciplinary ethics con-
sultations (e.g. ethics committees, ethics rounds), the position of power(lessness)
between doctors and nurses, the working relationship within the team and the
hospital, the relationship between nurses and hospital directors, etc. These con-
textual factors influence greatly the questions asked (or not), the problems sig-
nalled (or not), the solutions proposed (or not).
A good observer of the ethical dialogue in health care will quickly note that
the process and outcome of ethical reflection is influenced not only by institu-
tional factors, but also by other external factors, such as the position of power
between doctors and nurses, the working relationship within the team and in the
hospital, the relationship between nurses and hospital directors, etc. The influ-
ence of professional relationships and positions on ethical decision-making
processes is expressed in the concept of the ‘moral position of the nurse’. This

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means that the actual position of nurses in an institution of care is crucially impor-
tant for the way in which they deal with ethical problems and participate (or not)
in ethics consultations. Ethical problems are predominantly anchored in institu-
tional, professional and relational dimensions. Ethical problems occur in an
atmosphere of power/helplessness, emotional concern, indifference, efficiency
and cost-effectiveness, pressure at work, (in)competence etc. This atmosphere
determines who expresses which moral convictions and the kind of influence they
will have on care. This is an important aspect for the teaching of professional
ethics to nurses. It has to be taken into account that nursing practice consists of
having certain attitudes and initiatives within institutions in whose framework
the nurse–patient relationship is effected.
At this institutional level nurses are predominantly summoned to their respon-
sibilities as employees of the institution. Basically, as members of a health care
institution, nurses have to work toward the aims of the institution. According to
Arie van der Arend, in real terms this mostly results in the incorporation of
nurses into the prevailing business-like culture of hospitals, where matters of
efficiency and savings become ever more predominant.49 Yet one has to imple-
ment this policy in an environment where the well-being of patients comes first
and foremost, and where patients approach nurses primarily because of their
human and professional qualities. Being both employees and nurses, nurses are
confronted with both sides of the organization. This makes them easy victims of
conflicts between different responsibilities. 50 For example, when decisions about
the allocation of resources are made according to a utilitarian cost–benefit ratio-
nale, what is ‘good’ for the economic efficiency of a hospital is not necessarily
perceived as ‘good’ by the individual patient. 51 This simple example shows in
what way the institutional context of nursing can hinder and sometimes even
obstruct the work of caring and the development of caring attitudes.
A contextual model of nursing ethics education has to take into account that
ethics is primarily concerned with a view of the good life and that nurses require
not only norms and treatment protocols established by budget-conscious admin-
istrators but especially ends and values for which they can strive. Nurses want
to be more than just people carrying out specific functions or fulfilling certain
roles. They also want their work to have meaning; they want to be engaged in
something worth while. Without a view of the fundamental goals of nursing care,
it becomes difficult, if not impossible, to motivate nurses. A fundamental view of
nursing cannot be reduced to a set of strategic aims such as preventing nursing
errors or providing technically competent care. Managers need to provide nurses
with a meaningful working environment in which they are transformed from
passive, contractual employees into motivated members of an orientated and
meaningful health care organization.
We could state that, with the organizational-policy-based component of care,
we are increasingly confronted with a ‘third’ party, which, using its direct or
indirect influence, orchestrates the ethical dialogue. A characteristic of this third
party is that it deploys initiatives outside the nurse–patient relationship that deter-
mine the circumstances and peripheral conditions of nursing practice. It is
problematic that institutional–organizational factors mostly do not become
explicit as such, hence the absence of an ethical touchstone. Consequently, a
development has taken place whereby an increasingly important role is

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 A fundamental ethical approach to nursing 505

attributed to management in ethical care questions. Discussing ethics is no longer

a matter for nurses or other caregivers alone, but also for institutions of care as
a whole, including the policy makers. This means that those responsible for policy
have to be explicit about ethical questions and the choices made. A solid contex-
tual nursing ethics education could help to make nurses and managers in nursing
more conscious of the organizational embeddedness of ethical practices.

Conclusion
The major point in this article is that the kind of nursing ethics education that is
given follows on from the theory that is held of nursing. With the caring rela-
tionship as the ordering principle, nursing ethics education would have a differ-
ent emphasis than it would have with more task- or product-orientated theories.
A continuing dialogue between theories and models of nursing and ethics is a
major task in the intellectual history of the nursing profession. On the basis of
the views about the fundamental background of nursing that have been devel-
oped in this article, three guidelines for nursing ethics education can be summa-
rized as follows:
1) The education of nurses should, first of all, promote the cultivation of an
ethical sensitivity on the part of nurses. This refers to the capacity to discern
the ethical meaning of a particular situation and to respond accordingly.
2) Integral ethics education is possible only if the ethical vocabulary used in edu-
cation is broadened. Along with rationalistic ethical concepts (ethical princi-
ples, judgements, methods of analysis, etc.) there must also be room for
concepts such as personality, virtues, attitudes, emotions and so forth. A
broader ethical vocabulary obviously also requires a broader perspective for
ethics education as a whole. Besides introducing nurses to essential ethical
theoretical knowledge (e.g. the image of humanity that we presuppose
when reflecting on ethical matters), greater attention should be devoted to the
cultivation of virtuous attitudes and affective capacities.
3) Special attention should be paid to the contextual embeddedness of ethical
behaviour. This implies that projects in ethics education should not be one-
sidedly focused on nurses alone, but also on the context in which nurses must
manifest themselves as ethical agents. Educators are responsible for imparting
knowledge to students and ensuring that they develop the needed skills to
recognize moral considerations in the professional context. However, it is
health care administrators who create conditions in the workplace that can
either facilitate or prohibit an employee from making use of this training.

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