Must We Be
Courageous?
by Ann B. Hamric , J ohn D . arras , and margaret E . mohrmann
Courage is indispensable. Telling caregivers they must be courageous in difficult circumstances is sometimes a backhanded endorsement of oppression, however.
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he notion of virtue in general, and courage in particular, has had a hard time integrating itself into the everyday lexicon of bioethics. Following the lead of enlightenment moral philosophy, which concentrates on the theory of right action as opposed to the ancient Greeks’ emphasis on the development of good character, bioethics, with some notable exceptions,1 has tended to relegate consideration of the virtues to the sidelines of moral argument. Recently, however, there have been calls for the necessity of “moral courage” in the context of clinical ethics. As nurses, physicians, and other health care professionals confront a variety of moral contexts in which the virtue of courage is invoked to “do the right thing,” stand up for patients’ rights, and uphold the ethical standards of their professions, they are increasingly reminded of their moral duty to exhibit courage in the face of institutional obstacles to the proper care of their patients.2 For example, a nurse’s hesitation to approach a physician
Ann B. Hamric, John D. Arras, and Margaret E. Mohrmann, “Must We Be Courageous?,” Hastings Center Report 45, no. 3 (2015): 3340. DOI: 10.1002/hast.449 May-June 2015
to request increased sedation for an agitated patient out of fear of retaliation is represented in one article as a lack of courage.3 In this paper we offer a critical assessment of such invocations of courage. While we find courage to be an indispensable virtue in some challenging contexts, in other settings we find invocations of courage to be both an unfortunate endorsement of an oppressive status quo that can divert attention from the real problems and an undesirable and potentially destructive strategy within health care institutions whose goal is medically excellent and morally good clinical practice. As we shall argue, a call to virtuousness is not always virtuous. The Neglect of Virtue Ethics
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e begin with a brief inquiry into the relative neglect of virtue both in modern moral philosophy and in bioethics. Contemporary bioethics, it might fairly be said, has been premised upon the two main pillars of Enlightenment moral philosophy, utilitarianism and Kantianism. Whereas the ancient Greeks tended to ask and traditional virtue H AS TI N GS C EN TE R RE P O RT
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ethicists echo the global question, what is the best kind of life?, utilitarians and Kantians tend to focus on the much narrower question of what makes right action right. Virtue ethics, in general, has concentrated on what is required to produce a good person with good character, implying that right action will somehow flow from the right set of moral dispositions. Enlightenment moral theorists set questions of character aside, contending that what really mattered was either the production of the best overall consequences (utilitarianism) or the agent’s intent to do the right thing solely because it was one’s duty (Kantianism). Both of these Enlightenment ethical theories thus put virtue on the back burner, and, in addition, neither could make much sense of supererogatory action—actions beyond the call of strict duty that are rightly praised for being, say, exceptionally courageous but that are viewed as being morally optional for most moral agents. By focusing exclusively on the maximal production of good consequences, utilitarianism would seem to require morally supererogatory actions so long as they conduce to producing the best overall net outcomes.4 This should be a deeply troubling result, implying that all of us should be prepared to act as moral saints all the time, notwithstanding personal risks that are often outweighed by the production of maximal social welfare. For their part, Kantians also have trouble making sense out of traditional theories of virtue ethics. For Kant, all that mattered was doing one’s duty for the sake of duty.5 Accordingly, he defined moral virtue as a disposition to act out of a sense of duty. A virtuous character would help us resist the temptations to act against our moral duty, which was independently defined. The virtues were thus not a separate theoretical category of moral inquiry, a set of moral dispositions that would lead us to act rightly in a wide variety of circumstances. For Kant, the virtues were something of an afterthought, defined exclusively 34 HASTI N G S C E N T E R R E P ORT
as a means of fortifying our ability to act out of a sense of moral duty—to conform to the categorical imperative. One important implication of this line of reasoning is that, similar to utilitarian theory, Kantian moral theory harbors no resources for dealing with supererogatory actions that go beyond our moral duty. Anything apart from or beyond duty is viewed as simply irrelevant to ethical assessment. Thus, neither of these two dominant moral theories within bioethics would appear up to the challenges facing health care professionals in their day-to-day struggles both to do right by their patients and to keep their jobs. Utilitarians would insist that clinicians always subordinate their own personal welfare and career aspirations to achieving the best overall consequences for society.6 Kantians, on the other hand, would seem incapable of theorizing situations in which health professionals actually transcend the call of strict duty, placing themselves or their careers in harm’s way for the sake of doing good for their patients.7 Defining Courage
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ecause neither of these dominant theories within bioethics appears capable of doing justice to the moral quandaries confronting today’s clinicians, we find ourselves thus thrown back upon the moral resources of the virtue ethics tradition in our search for an adequate understanding of the proper role of courage in medical practice. Here we follow Aristotle in emphasizing three key components of courageous action: Courageous actions exhibit thoughtful deliberation. Actors who respond instantaneously in battle to the death of a comrade in arms with remarkably bold and ruthless behavior are often taken to be paragons of courage, but Aristotelian virtue theory would say that their actions are impulsive, viciously and unthinkingly retributive, rather than truly courageous.8 Similarly, a nurse or doctor
who reacts in immediate and unexamined outrage to a perceived moral blunder by immediately storming into an administrator’s office to demand redress is not exhibiting courage. A courageous agent rationally tests the apparent call for courage by thinking carefully about the situation from all sides and then weighs the pros and cons of a contemplated action, taking into account both the good she could do and the threats to her own welfare, professional ambitions, or life. Courageous action is thus an instance of practical reason.9 Courageous action requires a difficult, painful, or dangerous situation. In order for an action to be deemed courageous, the stakes have to be high.10 There has to be a perceived personal cost to doing the right thing. In the context of our inquiry, this requirement is easily satisfied. Clinicians are sometimes required to put their own personal or professional status and welfare on the line in order to live up to their professional obligations. Physicians and nurses who serve as the first line of defense against Ebola have shown remarkable courage as they take great personal risks to care for needy patients.11 In a different example of courage in the face of risk, two Texas nurses complained repeatedly about a physician’s unsafe medical practices, both to their administrators and to the state medical board. Both nurses were fired and charged with criminal offenses. After almost three years of legal action, they were exonerated; the physician in question and hospital and government officials were indicted.12 The truly courageous agent pursues a morally worthy goal or ideal. Aristotle moralizes courageous behavior; actions done with evil or unethical intent cannot be “courageous.”13 This component makes the phrase “moral courage” a tautology. There is no salient distinction to be drawn between “physical courage” and “moral courage,” even if not all instances of courageous behavior involve physical risk. The crew of bank robbers in the film The Italian Job were very May-June 2015
thoughtful, skilled, and resourceful, and they faced great personal risks, including incarceration, physical injury, and death. But Aristotelian virtue theory would balk at the notion that they acted courageously in attempting to knock over, for their personal enrichment, a bank crammed with gold bricks. Some might want to challenge this element of traditional virtue theory’s moralized account of courage, arguing that bad people can act courageously even in pursuit of unethical projects: corrupt researchers may take great personal risks when they falsify data for their own aggrandizement; maverick clinicians may risk their reputations and their employment, as well as their patients’ lives, on novel interventions in the hope of fame and fortune as heroic medical pioneers. But we need not tarry over this controversy. The moral situations with which we are concerned here feature health care professionals taking serious risks in order to advance the well-being of their patients or to respect their moral rights. These are indisputably morally worthy goals. We also follow Aristotle in defining virtue, and hence courage, as a mean between two extremes.14 On the one hand, we have cases of cowardice, where individuals abandon their stations at the slightest risks to themselves. On the other hand, we have cases of foolhardy action, where individuals dive into significantly risky situations without giving any thought to either their ability to meet the challenges or their personal welfare. The Aristotelian mean between these extremes is courageous action— action requiring thoughtful fortitude in standing one’s ground in order to do the right thing. The courageous agent takes appropriate risks in the course of doing her duty, but she does not take thoughtless risks or suicidal risks beyond any that might be necessary to do her duty.15 Finally, we agree with Aristotle that the appropriate mean between extremes cannot be deduced from any rationalistic algorithm; May-June 2015
the proper exercise of virtue requires good judgment or practical wisdom (phronesis).16 This virtue theoretic approach to courage acknowledges the often extreme and problematic complexity of some moral decisions. Should a nurse challenge the chairman of the surgery department, whose policies may be inadvertently placing the rights or welfare of the nurse’s patients at risk? Perhaps, but perhaps not, especially if the nurse can reasonably expect the chair of surgery to come down on him like a ton of bricks, threatening his ability to function as a nurse at that hospital. And even if the nurse decides that protecting his patients’ interests and rights should be his uppermost concern, he will have to think long and
for patients with multiple drug–resistant tuberculosis or HIV can expose health care providers to serious health risks. In the past, some physicians refused to care for HIV-infected individuals on the ground that they had an absolute right in deciding whom to treat. To their credit, both the nursing and (eventually) the medical professions came to the conclusion that taking such risks simply comes with the job. Professionals occupying these roles have a moral duty to care for patients with contagious or infectious diseases, and for this they require the virtue of courage. They need not take excessive or suicidal risks, but they must on occasion assume some serious risks. A second, more remarkable type
neither utilitarianism nor Kantian moral theory does justice to health care professionals’ day-to-day struggles both to do right by their patients and to keep their jobs. hard about the best, least disruptive, or least personally threatening way in which his ends might be achieved. The courageous nurse or physician must wisely choose her battles. A Typology of Courage
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his brief inventory of the essential features of courage concludes with an important typology of different kinds of courage. On the one hand, as Kant emphasized, courage is a virtue required for performance of one’s duty. The soldier has a duty to stand his ground and fight until ordered to retreat. If he should flee at the sight of approaching enemy soldiers, he could rightfully be accused of cowardice and dereliction of duty. Clinicians often find themselves in situations where they are morally obligated to take risks, within a certain range of reasonableness, in order to secure the rights and welfare of their patients. For example, caring
of courage involves actions that go beyond the call of duty, actions that can properly be called heroic. Here, again, we can call on the example of those who care for persons stricken with the highly contagious and dangerous Ebola virus. The rate of death for those infected is shockingly high, and the possibility of effective treatment uncertain, yet many health care professionals have volunteered to work on the frontlines where the disease is epidemic. Many others in nonaffected areas have shown up for work when infected persons have been brought to them for care, and some have paid the ultimate price with their lives. In extreme circumstances like this, we cannot reasonably say that all health care providers have a strict moral duty to risk death in caring for their patients. These people not only have obligations to their patients, but in many cases they also have obligations to their spouses, partners, and H AS TI N GS C EN TE R RE P O RT
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children, and any health care worker might also morally put her own life before that of a patient. A universal professional morality can conclude that health care providers have a strict duty to care for HIV- or tuberculosisinfected patients, who pose much less risk, but it cannot impose such a duty in extreme cases of risk, such as that posed currently by the Ebola epidemic. About such cases, we can make two observations. First, we can say that even though a universal ethics cannot impose a duty to maintain one’s role at risk of death in such extreme situations, especially when responsible medical authorities do not or cannot provide frontline health workers with adequate prophylactic protections, some individuals may impose such an obligation on themselves. Realizing full well that taking such risks does not come with the job of being a nurse or physician, they may reasonably think that taking such risks is essential to being the kind of nurse or physician they want to be. Providing health care even in cases like an Ebola outbreak is thus required by their own personal moral or professional code, even if not by some universal code. Second, we can say that those who do take such risks should be recognized as performing supererogatory actions (as acting heroically). They are worthy of praise even if those who fail to fulfill their usual duties, much less volunteer, in such circumstances cannot reasonably be morally criticized. We conclude, against the utilitarians, that health care providers are not morally obligated to perform very risky supererogatory actions that conduce to maximal social welfare, and we also conclude, against Kantian ethical theorists, that those who go beyond the call of duty are deserving of (additional) moral praise. Courage in Clinical Practice
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rawing on these historical and philosophical analyses of the virtue of courage, we now turn to the
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clinical context—the environment and situations within which health professionals carry out their vocations—to consider ways in which courage is and should be, and is not and should not, be called for there. We begin with making the case for courage as a required virtue for good professional clinical practice for all health professionals. We then argue against the unqualified promotion of courage as a desirable virtue in confronting moral dilemmas within medical institutions. The case for courage. Although it may be obvious that it takes some degree of courage to care for persons with certain highly contagious diseases, that recognition does not encompass all that requires bravery in clinical practice. But before we expand the scope of courage further, it should be noted that, in most instances, it is not courage that is needed for clinicians to remain present for the physical agony and psychological distress of patients. Tragedy is hard to witness, but it is not contagious. The idea, occasionally articulated, that “I cannot survive such an encounter” is only metaphorical, and the fear that underlies this can be close to absurd. The error lies in misinterpreting the threat, thinking that another’s pain is in fact something I should fear as a true risk to myself. Courage, however, has traditionally been construed as the confidence and will to face real threats and thus depends upon an accurate, thoughtful assessment of the situation and its risks. A disturbed patient in the emergency department wielding a knife is quite a different kind of threat to a clinician’s well-being from a patient in the burn unit screaming in pain as the debridement begins. The danger of the former does require courage—and some prudence—to face; the suffering of the latter requires not courage but an appropriate combination of compassion and skill. That important point, however, must immediately be tempered. It is reasonable to assert that a clinician has no physical cause to fear a
patient’s severe burn, cancer, dementia, or the manifestations of suffering that come with those afflictions and that, therefore, courage is not required to attend well to such patients. What is required is clarity about whose well-being is actually at stake. But it is also correct and important to recognize that a clinician who has himself survived seriously disfiguring trauma or a long struggle with chemotherapy or who is caring for a parent with Alzheimer’s disease may well need to call on courage in the face of the kinds of fearful reactions—flashbacks and flash forwards—that can be triggered by certain patients. Someone who has suffered sexual abuse is likely to need considerable courage even to stay in the same room with a patient who is a known sexual predator. Someone who struggled through childhood in the home of an alcoholic parent may need to be very brave to respond not only with technical competence but also with respect and empathy to an alcoholic patient in liver failure who is still wielding the emotional weapons of the committed addict. We cannot know the courage it takes for any nurse or physician or therapist to approach, much less to give attentive and compassionate care to, a patient who is the embodiment of her own nightmares or unresolved grief. Aristotle said it: “What is frightening is not the same for everyone.”17 It is not for us to judge the rationality of such practitioners’ deeply implanted fears, but rather, to acknowledge and praise that courage when we see it. Aristotle’s analysis of the virtues is the foundation of the West’s developed understanding of courage, but he considered courage primarily in the context of war. Philosopher and ethicist Lisa Tessman asserts that “Aristotle did not anticipate the burden of courage because he did not expect the demand for courage to be so constant.”18 Surely, like periodic wars, certain contagious diseases and certain situations, depending on one’s own history, will at times require courage of the clinical practitioner. May-June 2015
But there is another aspect of clinical practice that demonstrates a more constant, recurring need for courage. The courage more persistently called for in clinical medicine is the reliable disposition to approach with appropriate confidence situations that are fraught with the realistic fear of getting it wrong and causing harm. This is the courage required to care for the severely burned patient mentioned earlier—not courage to be in the presence of his suffering, but fortitude to risk error and failure in the treatment of his affliction. No matter how much clinicians learn, how carefully they hone their skills, they will still not have complete control over patients, over illnesses and outcomes, or even over their own abilities. As philosopher Margaret Urban Walker so effectively reminds us, our responsibilities always outstrip our control.19 Clinicians need courage to competently discharge their inescapable obligations to decide and to act despite irreducible uncertainty. In the face of partial knowledge and unpredictable outcomes, what requires courage in medical care is the ubiquitous and quite real fear of costly, damaging error. The stakes are high, the responsibility daunting, the resources inadequate and deceptive. This is not only a matter of making the right diagnosis, administering the correct dose of the correct medication, or successfully performing the appropriate procedure. Although these are all fundamental components of clinical practice that can never be fully mastered—that are never free of the risks of insufficient information, imperfect reasoning, and distracted attention—they are not the only things for which clinicians are responsible and not the only things that can go badly wrong despite the best of training and the best of intentions. For example, it takes courage to give bad news to a patient or a family, not so much for the clinician to endure the discomfort of their grief (the point made previously), but rather in order to face honestly the possibility that she may carry out that task quite May-June 2015
poorly and thereby compound their pain, perhaps irreparably. Courage enables the practitioner to take on that responsibility anyway, with the appropriate level of self-aware confidence—and doing so should motivate the virtuous and compassionate clinician to learn how to do it better. The weighty responsibilities of good health care cannot be avoided, but they also are usually neither entirely controllable nor fully satisfiable. It takes courage to work well in such a world. Moreover, courage is a mean, as Aristotle taught—a balance between cowardice and foolhardiness—and the manifestations of the two nonvirtuous extremes help clarify the value of courage in the clinical context.
heedless of the dangers. As we noted earlier, courage, like the other virtues, requires practical wisdom, phronesis, and it may be dangerous when deployed in the absence of that capacity for wise discernment. Given both the need for courage for good clinical practice and the dangers of heroic blindness, it is surely important for the field of bioethics to consider carefully the nature of “clinical courage”: what it is and what it is not, how it may best be evoked—identified, taught, modeled, encouraged, praised—and the toll it can take. The daily practice of nursing, doctoring, and other forms of health care does require courage with a frequency not imagined by Aristotle. What this aspect of professional practice costs
Given both the necessity of courage for good clinical practice and the dangers of heroic blindness, bioethics MUST consider carefully the nature of “clinical courage.” Clinical cowardice, for example, may be in play when a clinician simply avoids a difficult conversation either by not having it at all or by bulldozing through it in order not to have to see the effects of the blundering words. Similarly, it may be cowardice that leads a clinician to use the reality of insufficient information and unpredictable outcomes as reason to insist on continuing a course of treatment that seems clearly futile and even inhumane. Foolhardiness can also take many forms. Courage is the virtue of approaching realistic fears or threats with appropriate confidence. It is not unwarranted certainty, bravado that disregards danger, or the rash offering of an empty hope. It is not blindly overconfident bluster that wades into difficult conversations or risky situations without caring to see how much harm is done, or how inept the performance, or to learn how to do it better.20 Courage is a complex virtue, not an easy, mindless charge forward
and how it may best be supported are questions worth bioethicists’ best efforts. The case against courage. The kind of “moral courage” being called for in recent literature, especially in the field of nursing,21 is, however, quite another matter. For the most part, it is being touted as the antidote to moral distress, as the virtue required of a clinician who chooses to speak out against what he believes to be moral error and must do so in the context of fear—fear of some sort of retaliation, on the one hand, and fear of loss of personal integrity on the other. There is no question that what is being called for is indeed courage; the fears, unfortunately, are too often realistic. The problem lies in valorizing that courage, as though it, too, were essential for good professional practice and even for one’s own wellbeing, despite the obvious toll it takes and despite the fact that the situations calling for courage could—and should—be otherwise, unlike the H AS TI N GS C EN TE R RE P O RT
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clinical encounters discussed above. It is a fundamental error to assume that the courage needed for a particular clinician to request an ethics consultation in a rigidly hierarchical hospital is as unavoidable and as definitive of good health care as the courage needed to carry out well the responsibility of telling parents that their infant daughter is dying. Clinicians can experience negative consequences associated with courage whether they act courageously or find it impossible to do so. This “dark side” of courage is exemplified in a study, by Elisa Gordon and one of us (Ann Hamric), of nurse access to ethics consultation services.22 Twice as many nurses wanted to call for an ethics consultation as actually called. In exploring the reasons for this disturbing pattern, the study found that nurses expressed moral distress at their inability to act on their ethical obligations to their patients. They reported a significantly higher perceived level of risk in the situation than did nurses who called for a consultation, and they experienced significantly higher regret than did nurses who obtained a consultation, regardless of consequences. One nurse who did not call for a consultation, ostensibly because there “really wasn’t time,” stated, “You know maybe there was enough time. And I didn’t realize I had that avenue. And I don’t know if it was because [one parent] was a physician in the hospital, politically there was just—I don’t know. But I was so berated in that situation, I didn’t have enough courage to then, you know, I just was like, okay, I’m wrong, I’m bad, that’s it” (p. 245). This nurse not only blamed herself for her lack of courage but also went on to criticize her own character. The moral residue expressed in many of the nurse narratives elicited in this study had persisted for years. Because these nurses believed they knew what they should have done ethically but were unable to act—the definition of moral distress—and because these situations occurred repeatedly, they experienced both 38 HASTI N G S C E N T E R R E P ORT
significant moral distress and the moral residue buildup that Elizabeth Epstein and one of us (Hamric) have characterized as the Crescendo Effect. 23 There are already enough root causes of moral distress without adding “lack of courage” to the list. The painful experiences described by the nurses in this and countless other studies resulted from the dysfunctional systems within which these nurses worked, not from character deficits. The power of this moral residue was underscored by one study participant who refused to allow her story to be included in the findings in spite of the authors’ disguising most of the features of the case to prevent identification. In her final comment, she said, “They [her institutional leaders] will know it was me, and I need to work here.” The case in question was five years old when this nurse refused to let it be used. Conversely, providers who do act courageously can also experience negative consequences. In the Gordon-Hamric study, nurses who exhibited courage were often ostracized by other team members. They experienced alienation in communications with team members who felt that they had gone above their level of authority in calling for an ethics consultation. They endured angry reactions from colleagues (particularly physicians) and were even threatened with loss of their jobs. In situations requiring courage, providers have a strong sense of isolation that is the antithesis of effective team communication. Requiring the exercise of courage can perpetuate dysfunctional teamwork as teams become polarized and relationships strained. Courage always comes at a cost, as we’ve said, but this is an unacceptable and unnecessary price. It should be clear that exercising courage is not sufficient to address moral distress in dysfunctional systems and certainly should not be seen as a “magic bullet” to eliminate moral distress. Although clinicians may honor their own moral agency in taking courageous action in the face of
unethical practice, such action alone will not deal with the unit and institutional levels at which moral distress operates.24 Lisa Tessman laments that “there is a level of courage that is needed only for facing what no one should have to face.”25 She argues that virtues that seem to be called for and praiseworthy under conditions of oppression are “burdened” because, although they may serve well the oppressed group’s survival within and subversion of those conditions, they cannot contribute to the individual virtuous person’s flourishing, contrary to the Aristotelian definition of virtues as primarily doing just that. If it truly takes courage—that is, if the fears of retaliation and harm are realistic—for a nurse, a resident physician or medical student, a pharmacist or social worker, or anyone not in the top rank of the hierarchy in a medical center to question the way things are done or to speak up for what they believe to be right, then conditions of oppression exist, and Tessman’s analysis is telling. Tessman lodges several complaints about invocations of courage. One is that the call for courage, under oppressive conditions, is constant; there is no break from having to consider putting oneself in harm’s way in order to maintain integrity. This is a significant stress added on to all the other, truly inescapable stresses of a life in health care; it is surely difficult enough that clinical care itself requires courageous professionals. Another, related problem is that an emphasis on courage deflects attention and siphons energy away from other virtues that need cultivation and expression—virtues like wisdom, compassionate caring, and justice— and away from the human relational calls of daily situations, the need to be fully present for and with others (not incidentally, contributing to the sense of isolation noted earlier). In a similar vein, Amélie Rorty cautions us that the promotion of courage may result in the tendency to misconstrue encounters as nothing more than May-June 2015
opportunities for its display. She says that a person intent on being courageous “tends to interpret situations as presenting obstacles to be overcome, seeing situations as occasions for confrontation and combat. . . . The confidence that is part of courage tends to dampen imaginative foresight directed to avoiding oppositional confrontation.”26 This overemphasis on courage can result in precisely the distortions of courage that Aristotle warned against, perhaps especially foolhardiness. The “courageous hero” may fail to appreciate what should be appropriately feared in the situation, such as further shrinking of one’s capacity for compassion or coming another step closer to burnout and a loss of vocation. The “courageous hero” may become overconfident of her grasp of the situation and fall into the traps of moral arrogance and certitude. Although much of the recent literature on courage warns that these traps must be carefully avoided, the promotion of such courage may lead the clinician straight into them. Valorizing courage that is required only because of unethical institutional structures seriously risks promoting a diminished level of patient care as well as a diminished level of collegiality and vocational satisfaction. Insistence on courage in everyday practice implies that conditions of fear, danger, or risk are omnipresent and that a provider cannot be ethical without courage. Within moral and just institutions, many if not most caregiving situations should not require courage beyond what may be inseparable from good care of patients, as discussed above. Any invocation of the need for individual provider courage outside those limits should be coupled with careful investigation into systems and cultures of practice to ensure that they are ethical environments that promote doing the right thing. Research on moral distress reveals that these systems and cultures can foster recurring situations that challenge a provider’s moral integrity. Focusing on the moral virtues of May-June 2015
individual providers is only one part of creating more ethical practice environments and may be ineffective if power hierarchies and dysfunctional systems remain unchanged. One author went so far as to say that we need to build environments that support courage.27 In our view, the opposite is true: we need to build settings where courage is rarely needed to do the right thing and practice ethically. Mounting data show that ethical work environments are good for patients and providers alike. If health care professionals are routinely required to exhibit courage to survive their practice in an institution, this should be a source of concern, not celebration. Courage should not be necessary for any pro-
and discernments—when promoted as both necessary and unproblematically virtuous, may feed a “hero’s” inclinations toward moral arrogance and certitude but will do nothing to correct the fundamental injustice of hierarchical structures of power, position, and gender that continue to silence the moral voices of engaged participants. As long as courage is necessary to practice the medical professions well—and it will be necessary as long as people get seriously ill and die— then it is important to recognize it, name it, encourage it, and reward it. The challenge is to look beyond the nobility of the courage called for by the nature of caring for the sick in order to see the damage inflicted by
Courage should not be necessary for any health care professional to ask a question or make a suggestion regarding a patient’s care. fessional to ask a question or make a suggestion regarding a patient’s care. The implications of such excessive valorization of courage are significant. Are we to build this expectation into professionals’ job descriptions? Should we fire providers who are unable to be courageous in the face of significant risk? Such expectations are problematic to measure, and such actions difficult to justify in ways that stand up to objective scrutiny. Making heroes of those who behave courageously in relation to their institution and its hierarchies avoids the question of what is being done to relieve the conditions of oppression. Oppressive conditions—unresponsive systems, bullying clinicians, job insecurity, and the like—may be tolerated not only as unalterable but even as acceptable because they nurture desirable practices of courage. The kind of courage needed only for facing what no one should have to face—the possibility of real and significant harm if one expresses or acts on one’s best moral instincts
calls for courage that are not so entailed and to then work (courageously) to diminish the latter call. To be sure, courage should be celebrated. But demanding individual courage is no substitute for institutional justice. In Remembrance
John Arras died shortly before we received the proofs of this article. Collaborating with John, whatever the project or conversation, was always an intense and joyful adventure: stimulating, challenging, rigorous, and fun. We treasure our memories and mourn our loss of a beloved friend and inspiring colleague. Notes
1. See, for example, E. Pellegrino and D. C. Thomasma, The Virtues in Medical Practice (New York: Oxford University Press, 1993); Daniel Sulmasy, “Should Medical Schools Be Schools for Virtue?,” Journal of General Internal Medicine 15, no. 7: 514-16. 2. C. V. Caldicott and K. Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third-Year Medical Students,” Academic Medicine 80 (2005): 866-73; V. D. Lachman et al., “Doing the Right Thing: H AS TI N GS C EN TE R RE P O RT
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Pathways to Moral Courage,” American Nurse Today 7, no. 5 (2012): 24-29; J. S. Murray, “Moral Courage in Healthcare,” Online Journal in Nursing 15, no. 3 (2010). 3. Lachman et al., “Doing the Right Thing,” 25. 4. J. O. Urmson, “Saints and Heroes,” in Essays on Moral Philosophy, ed. A. I. Melden (Seattle: University of Washington Press, 1958), 198-216, at 206. 5. I. Kant, Groundwork of the Metaphysics of Morals, trans. H. J. Paton (New York: Harper and Row, 1964). 6. This is not to suggest that utilitarians view the personal welfare of health professionals to be irrelevant. It is, rather, always subject to being overridden by countervailing social benefits. 7. Philosophers of both utilitarian and Kantian persuasions would most likely respond that their preferred moral theory is capable of accounting for supererogatory action with a bit of theoretical tweaking. We have found such attempts to be unconvincing, but this is not the place to argue our case. 8. Aristotle, Nicomachean Ethics, 1115b25. 9. For a robust defense of Aristotelian courage as an instance of practical reason, see D. Walton, Courage: A Philosophical Investigation (Berkeley: University of California Press, 1986), 59.
10. Aristotle focused on the threat of death in battle; see Nicomachean Ethics, 1115a25. 11. Time Magazine, “Person of the Year 2014: Ebola Healthcare Workers,” at http://www.time.com/ time-person-of-the-year-ebola-fighters. 12. American Nurses Association, “Justice Is Served: Texas Physician Pleads Guilty: ANA Gratified by Convictions in ‘Winkler County’ Nurses Whistleblower Case” (press release), November 8, 2011, http://nursingworld.org/FunctionalMenuCategories/ MediaResources/PressReleases/2011-PR/ Justice-is-Served-Texas-Physician-PleadsGuilty.pdf. 13. Aristotle, Nicomachean Ethics, 1115b20. 14. Ibid., 1106a5. 15. Some contemporary virtue theorists have discerned a tension or perhaps even a contradiction between Aristotle’s definition of virtue as a mean between extremes and the possibility of supererogatory action. How is it, they ask, that virtue is always a mean, while supererogation goes well beyond the mean in pursuing a good objective? Although the tide of contemporary scholarship seems to run against our position on the ultimate compatibility of supererogation and the doctrine of the mean, we are content to let this controversy play out in the virtue ethics literature while clinging, albeit tenuously, to the traditional view.
6.
16. Aristotle, Nicomachean Ethics, Book
17. Ibid., III.6. 18. L. Tessman, Burdened Virtues: Virtue Ethics for Liberatory Struggles (New York: Rowman & Littlefield, 2005), 125. 19. M. U. Walker, “Moral Luck and the Virtues of Impure Agency,” in Moral Contexts, M. U. Walker (New York: Rowman & Littlefield, 2003), 21-34, at 26. 20. Philosopher Amélie Oksenberg Rorty offers a particularly cogent discussion of the seductive attractions of “heroic” blindness, misread as virtue; A. O. Rorty, “The Two Faces of Courage,” Philosophy 61 (1986): 151-71. 21. Lachman et al., “Doing the Right Thing”; Murray, “Moral Courage in Healthcare.” 22. E. J. Gordon and A. B. Hamric, “The Courage to Stand Up: The Cultural Politics of Nurses’ Access to Ethics Consultation,” Journal of Clinical Ethics 17 (2006): 231-54. 23. E. G. Epstein and A. B. Hamric, “Moral Distress, Moral Residue, and the Crescendo Effect,” Journal of Clinical Ethics 20 (2009): 330-42. 24. Ibid. 25. Tessman, Burdened Virtues, 127. 26. Rorty, “The Two Faces of Courage,” 154. 27. Murray, “Moral Courage in Healthcare.”
Another Voice Practitioner Courage and Ethical Health Care Environments by justin oakley
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n “Must We Be Courageous?,”1 Ann Hamric, John Arras, and Margaret Mohrmann highlight how contemporary accounts of the virtue of courage in health care often gloss over deeper problems in the underlying health care systems themselves. They express particular concerns about the appropriateness and personal costs of exhortations to health professionals to take courageous action in circumstances where this is “required only because of unethical institutional structures” (p. 39). For instance, inadequate whistleblowing protection procedures leave clinicians exposed to unnecessary risks
Justin Oakley, “Practitioner Courage and Ethical Health Care Environments,” Hastings Center Report 45, no. 3 (2015): 40-42. DOI: 10.1002/ hast.454
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when reporting patient harms caused by clinician negligence or when speaking out against workplace bullying. The shortcomings of such procedures are unfair to individual practitioners when the onus is left on them to see that patients and colleagues are adequately protected. The failings of such systems are also unfair to the community, since relying in such ways on the extraordinary personal qualities of rare individuals risks distracting regulators’ attention from the underlying systemic issues. Hamric, Arras, and Mohrmann also bring out well how relevant background factors implicated in such harms can be overlooked by other approaches, such as utilitarianism, which tends to advise clinicians to respond well to present harms without necessarily investigating what caused a situation to become so dire in the first place. May-June 2015
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Courageous?
by Ann B. Hamric , J ohn D . arras , and margaret E . mohrmann
Courage is indispensable. Telling caregivers they must be courageous in difficult circumstances is sometimes a backhanded endorsement of oppression, however.
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he notion of virtue in general, and courage in particular, has had a hard time integrating itself into the everyday lexicon of bioethics. Following the lead of enlightenment moral philosophy, which concentrates on the theory of right action as opposed to the ancient Greeks’ emphasis on the development of good character, bioethics, with some notable exceptions,1 has tended to relegate consideration of the virtues to the sidelines of moral argument. Recently, however, there have been calls for the necessity of “moral courage” in the context of clinical ethics. As nurses, physicians, and other health care professionals confront a variety of moral contexts in which the virtue of courage is invoked to “do the right thing,” stand up for patients’ rights, and uphold the ethical standards of their professions, they are increasingly reminded of their moral duty to exhibit courage in the face of institutional obstacles to the proper care of their patients.2 For example, a nurse’s hesitation to approach a physician
Ann B. Hamric, John D. Arras, and Margaret E. Mohrmann, “Must We Be Courageous?,” Hastings Center Report 45, no. 3 (2015): 3340. DOI: 10.1002/hast.449 May-June 2015
to request increased sedation for an agitated patient out of fear of retaliation is represented in one article as a lack of courage.3 In this paper we offer a critical assessment of such invocations of courage. While we find courage to be an indispensable virtue in some challenging contexts, in other settings we find invocations of courage to be both an unfortunate endorsement of an oppressive status quo that can divert attention from the real problems and an undesirable and potentially destructive strategy within health care institutions whose goal is medically excellent and morally good clinical practice. As we shall argue, a call to virtuousness is not always virtuous. The Neglect of Virtue Ethics
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e begin with a brief inquiry into the relative neglect of virtue both in modern moral philosophy and in bioethics. Contemporary bioethics, it might fairly be said, has been premised upon the two main pillars of Enlightenment moral philosophy, utilitarianism and Kantianism. Whereas the ancient Greeks tended to ask and traditional virtue H AS TI N GS C EN TE R RE P O RT
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ethicists echo the global question, what is the best kind of life?, utilitarians and Kantians tend to focus on the much narrower question of what makes right action right. Virtue ethics, in general, has concentrated on what is required to produce a good person with good character, implying that right action will somehow flow from the right set of moral dispositions. Enlightenment moral theorists set questions of character aside, contending that what really mattered was either the production of the best overall consequences (utilitarianism) or the agent’s intent to do the right thing solely because it was one’s duty (Kantianism). Both of these Enlightenment ethical theories thus put virtue on the back burner, and, in addition, neither could make much sense of supererogatory action—actions beyond the call of strict duty that are rightly praised for being, say, exceptionally courageous but that are viewed as being morally optional for most moral agents. By focusing exclusively on the maximal production of good consequences, utilitarianism would seem to require morally supererogatory actions so long as they conduce to producing the best overall net outcomes.4 This should be a deeply troubling result, implying that all of us should be prepared to act as moral saints all the time, notwithstanding personal risks that are often outweighed by the production of maximal social welfare. For their part, Kantians also have trouble making sense out of traditional theories of virtue ethics. For Kant, all that mattered was doing one’s duty for the sake of duty.5 Accordingly, he defined moral virtue as a disposition to act out of a sense of duty. A virtuous character would help us resist the temptations to act against our moral duty, which was independently defined. The virtues were thus not a separate theoretical category of moral inquiry, a set of moral dispositions that would lead us to act rightly in a wide variety of circumstances. For Kant, the virtues were something of an afterthought, defined exclusively 34 HASTI N G S C E N T E R R E P ORT
as a means of fortifying our ability to act out of a sense of moral duty—to conform to the categorical imperative. One important implication of this line of reasoning is that, similar to utilitarian theory, Kantian moral theory harbors no resources for dealing with supererogatory actions that go beyond our moral duty. Anything apart from or beyond duty is viewed as simply irrelevant to ethical assessment. Thus, neither of these two dominant moral theories within bioethics would appear up to the challenges facing health care professionals in their day-to-day struggles both to do right by their patients and to keep their jobs. Utilitarians would insist that clinicians always subordinate their own personal welfare and career aspirations to achieving the best overall consequences for society.6 Kantians, on the other hand, would seem incapable of theorizing situations in which health professionals actually transcend the call of strict duty, placing themselves or their careers in harm’s way for the sake of doing good for their patients.7 Defining Courage
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ecause neither of these dominant theories within bioethics appears capable of doing justice to the moral quandaries confronting today’s clinicians, we find ourselves thus thrown back upon the moral resources of the virtue ethics tradition in our search for an adequate understanding of the proper role of courage in medical practice. Here we follow Aristotle in emphasizing three key components of courageous action: Courageous actions exhibit thoughtful deliberation. Actors who respond instantaneously in battle to the death of a comrade in arms with remarkably bold and ruthless behavior are often taken to be paragons of courage, but Aristotelian virtue theory would say that their actions are impulsive, viciously and unthinkingly retributive, rather than truly courageous.8 Similarly, a nurse or doctor
who reacts in immediate and unexamined outrage to a perceived moral blunder by immediately storming into an administrator’s office to demand redress is not exhibiting courage. A courageous agent rationally tests the apparent call for courage by thinking carefully about the situation from all sides and then weighs the pros and cons of a contemplated action, taking into account both the good she could do and the threats to her own welfare, professional ambitions, or life. Courageous action is thus an instance of practical reason.9 Courageous action requires a difficult, painful, or dangerous situation. In order for an action to be deemed courageous, the stakes have to be high.10 There has to be a perceived personal cost to doing the right thing. In the context of our inquiry, this requirement is easily satisfied. Clinicians are sometimes required to put their own personal or professional status and welfare on the line in order to live up to their professional obligations. Physicians and nurses who serve as the first line of defense against Ebola have shown remarkable courage as they take great personal risks to care for needy patients.11 In a different example of courage in the face of risk, two Texas nurses complained repeatedly about a physician’s unsafe medical practices, both to their administrators and to the state medical board. Both nurses were fired and charged with criminal offenses. After almost three years of legal action, they were exonerated; the physician in question and hospital and government officials were indicted.12 The truly courageous agent pursues a morally worthy goal or ideal. Aristotle moralizes courageous behavior; actions done with evil or unethical intent cannot be “courageous.”13 This component makes the phrase “moral courage” a tautology. There is no salient distinction to be drawn between “physical courage” and “moral courage,” even if not all instances of courageous behavior involve physical risk. The crew of bank robbers in the film The Italian Job were very May-June 2015
thoughtful, skilled, and resourceful, and they faced great personal risks, including incarceration, physical injury, and death. But Aristotelian virtue theory would balk at the notion that they acted courageously in attempting to knock over, for their personal enrichment, a bank crammed with gold bricks. Some might want to challenge this element of traditional virtue theory’s moralized account of courage, arguing that bad people can act courageously even in pursuit of unethical projects: corrupt researchers may take great personal risks when they falsify data for their own aggrandizement; maverick clinicians may risk their reputations and their employment, as well as their patients’ lives, on novel interventions in the hope of fame and fortune as heroic medical pioneers. But we need not tarry over this controversy. The moral situations with which we are concerned here feature health care professionals taking serious risks in order to advance the well-being of their patients or to respect their moral rights. These are indisputably morally worthy goals. We also follow Aristotle in defining virtue, and hence courage, as a mean between two extremes.14 On the one hand, we have cases of cowardice, where individuals abandon their stations at the slightest risks to themselves. On the other hand, we have cases of foolhardy action, where individuals dive into significantly risky situations without giving any thought to either their ability to meet the challenges or their personal welfare. The Aristotelian mean between these extremes is courageous action— action requiring thoughtful fortitude in standing one’s ground in order to do the right thing. The courageous agent takes appropriate risks in the course of doing her duty, but she does not take thoughtless risks or suicidal risks beyond any that might be necessary to do her duty.15 Finally, we agree with Aristotle that the appropriate mean between extremes cannot be deduced from any rationalistic algorithm; May-June 2015
the proper exercise of virtue requires good judgment or practical wisdom (phronesis).16 This virtue theoretic approach to courage acknowledges the often extreme and problematic complexity of some moral decisions. Should a nurse challenge the chairman of the surgery department, whose policies may be inadvertently placing the rights or welfare of the nurse’s patients at risk? Perhaps, but perhaps not, especially if the nurse can reasonably expect the chair of surgery to come down on him like a ton of bricks, threatening his ability to function as a nurse at that hospital. And even if the nurse decides that protecting his patients’ interests and rights should be his uppermost concern, he will have to think long and
for patients with multiple drug–resistant tuberculosis or HIV can expose health care providers to serious health risks. In the past, some physicians refused to care for HIV-infected individuals on the ground that they had an absolute right in deciding whom to treat. To their credit, both the nursing and (eventually) the medical professions came to the conclusion that taking such risks simply comes with the job. Professionals occupying these roles have a moral duty to care for patients with contagious or infectious diseases, and for this they require the virtue of courage. They need not take excessive or suicidal risks, but they must on occasion assume some serious risks. A second, more remarkable type
neither utilitarianism nor Kantian moral theory does justice to health care professionals’ day-to-day struggles both to do right by their patients and to keep their jobs. hard about the best, least disruptive, or least personally threatening way in which his ends might be achieved. The courageous nurse or physician must wisely choose her battles. A Typology of Courage
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his brief inventory of the essential features of courage concludes with an important typology of different kinds of courage. On the one hand, as Kant emphasized, courage is a virtue required for performance of one’s duty. The soldier has a duty to stand his ground and fight until ordered to retreat. If he should flee at the sight of approaching enemy soldiers, he could rightfully be accused of cowardice and dereliction of duty. Clinicians often find themselves in situations where they are morally obligated to take risks, within a certain range of reasonableness, in order to secure the rights and welfare of their patients. For example, caring
of courage involves actions that go beyond the call of duty, actions that can properly be called heroic. Here, again, we can call on the example of those who care for persons stricken with the highly contagious and dangerous Ebola virus. The rate of death for those infected is shockingly high, and the possibility of effective treatment uncertain, yet many health care professionals have volunteered to work on the frontlines where the disease is epidemic. Many others in nonaffected areas have shown up for work when infected persons have been brought to them for care, and some have paid the ultimate price with their lives. In extreme circumstances like this, we cannot reasonably say that all health care providers have a strict moral duty to risk death in caring for their patients. These people not only have obligations to their patients, but in many cases they also have obligations to their spouses, partners, and H AS TI N GS C EN TE R RE P O RT
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children, and any health care worker might also morally put her own life before that of a patient. A universal professional morality can conclude that health care providers have a strict duty to care for HIV- or tuberculosisinfected patients, who pose much less risk, but it cannot impose such a duty in extreme cases of risk, such as that posed currently by the Ebola epidemic. About such cases, we can make two observations. First, we can say that even though a universal ethics cannot impose a duty to maintain one’s role at risk of death in such extreme situations, especially when responsible medical authorities do not or cannot provide frontline health workers with adequate prophylactic protections, some individuals may impose such an obligation on themselves. Realizing full well that taking such risks does not come with the job of being a nurse or physician, they may reasonably think that taking such risks is essential to being the kind of nurse or physician they want to be. Providing health care even in cases like an Ebola outbreak is thus required by their own personal moral or professional code, even if not by some universal code. Second, we can say that those who do take such risks should be recognized as performing supererogatory actions (as acting heroically). They are worthy of praise even if those who fail to fulfill their usual duties, much less volunteer, in such circumstances cannot reasonably be morally criticized. We conclude, against the utilitarians, that health care providers are not morally obligated to perform very risky supererogatory actions that conduce to maximal social welfare, and we also conclude, against Kantian ethical theorists, that those who go beyond the call of duty are deserving of (additional) moral praise. Courage in Clinical Practice
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rawing on these historical and philosophical analyses of the virtue of courage, we now turn to the
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clinical context—the environment and situations within which health professionals carry out their vocations—to consider ways in which courage is and should be, and is not and should not, be called for there. We begin with making the case for courage as a required virtue for good professional clinical practice for all health professionals. We then argue against the unqualified promotion of courage as a desirable virtue in confronting moral dilemmas within medical institutions. The case for courage. Although it may be obvious that it takes some degree of courage to care for persons with certain highly contagious diseases, that recognition does not encompass all that requires bravery in clinical practice. But before we expand the scope of courage further, it should be noted that, in most instances, it is not courage that is needed for clinicians to remain present for the physical agony and psychological distress of patients. Tragedy is hard to witness, but it is not contagious. The idea, occasionally articulated, that “I cannot survive such an encounter” is only metaphorical, and the fear that underlies this can be close to absurd. The error lies in misinterpreting the threat, thinking that another’s pain is in fact something I should fear as a true risk to myself. Courage, however, has traditionally been construed as the confidence and will to face real threats and thus depends upon an accurate, thoughtful assessment of the situation and its risks. A disturbed patient in the emergency department wielding a knife is quite a different kind of threat to a clinician’s well-being from a patient in the burn unit screaming in pain as the debridement begins. The danger of the former does require courage—and some prudence—to face; the suffering of the latter requires not courage but an appropriate combination of compassion and skill. That important point, however, must immediately be tempered. It is reasonable to assert that a clinician has no physical cause to fear a
patient’s severe burn, cancer, dementia, or the manifestations of suffering that come with those afflictions and that, therefore, courage is not required to attend well to such patients. What is required is clarity about whose well-being is actually at stake. But it is also correct and important to recognize that a clinician who has himself survived seriously disfiguring trauma or a long struggle with chemotherapy or who is caring for a parent with Alzheimer’s disease may well need to call on courage in the face of the kinds of fearful reactions—flashbacks and flash forwards—that can be triggered by certain patients. Someone who has suffered sexual abuse is likely to need considerable courage even to stay in the same room with a patient who is a known sexual predator. Someone who struggled through childhood in the home of an alcoholic parent may need to be very brave to respond not only with technical competence but also with respect and empathy to an alcoholic patient in liver failure who is still wielding the emotional weapons of the committed addict. We cannot know the courage it takes for any nurse or physician or therapist to approach, much less to give attentive and compassionate care to, a patient who is the embodiment of her own nightmares or unresolved grief. Aristotle said it: “What is frightening is not the same for everyone.”17 It is not for us to judge the rationality of such practitioners’ deeply implanted fears, but rather, to acknowledge and praise that courage when we see it. Aristotle’s analysis of the virtues is the foundation of the West’s developed understanding of courage, but he considered courage primarily in the context of war. Philosopher and ethicist Lisa Tessman asserts that “Aristotle did not anticipate the burden of courage because he did not expect the demand for courage to be so constant.”18 Surely, like periodic wars, certain contagious diseases and certain situations, depending on one’s own history, will at times require courage of the clinical practitioner. May-June 2015
But there is another aspect of clinical practice that demonstrates a more constant, recurring need for courage. The courage more persistently called for in clinical medicine is the reliable disposition to approach with appropriate confidence situations that are fraught with the realistic fear of getting it wrong and causing harm. This is the courage required to care for the severely burned patient mentioned earlier—not courage to be in the presence of his suffering, but fortitude to risk error and failure in the treatment of his affliction. No matter how much clinicians learn, how carefully they hone their skills, they will still not have complete control over patients, over illnesses and outcomes, or even over their own abilities. As philosopher Margaret Urban Walker so effectively reminds us, our responsibilities always outstrip our control.19 Clinicians need courage to competently discharge their inescapable obligations to decide and to act despite irreducible uncertainty. In the face of partial knowledge and unpredictable outcomes, what requires courage in medical care is the ubiquitous and quite real fear of costly, damaging error. The stakes are high, the responsibility daunting, the resources inadequate and deceptive. This is not only a matter of making the right diagnosis, administering the correct dose of the correct medication, or successfully performing the appropriate procedure. Although these are all fundamental components of clinical practice that can never be fully mastered—that are never free of the risks of insufficient information, imperfect reasoning, and distracted attention—they are not the only things for which clinicians are responsible and not the only things that can go badly wrong despite the best of training and the best of intentions. For example, it takes courage to give bad news to a patient or a family, not so much for the clinician to endure the discomfort of their grief (the point made previously), but rather in order to face honestly the possibility that she may carry out that task quite May-June 2015
poorly and thereby compound their pain, perhaps irreparably. Courage enables the practitioner to take on that responsibility anyway, with the appropriate level of self-aware confidence—and doing so should motivate the virtuous and compassionate clinician to learn how to do it better. The weighty responsibilities of good health care cannot be avoided, but they also are usually neither entirely controllable nor fully satisfiable. It takes courage to work well in such a world. Moreover, courage is a mean, as Aristotle taught—a balance between cowardice and foolhardiness—and the manifestations of the two nonvirtuous extremes help clarify the value of courage in the clinical context.
heedless of the dangers. As we noted earlier, courage, like the other virtues, requires practical wisdom, phronesis, and it may be dangerous when deployed in the absence of that capacity for wise discernment. Given both the need for courage for good clinical practice and the dangers of heroic blindness, it is surely important for the field of bioethics to consider carefully the nature of “clinical courage”: what it is and what it is not, how it may best be evoked—identified, taught, modeled, encouraged, praised—and the toll it can take. The daily practice of nursing, doctoring, and other forms of health care does require courage with a frequency not imagined by Aristotle. What this aspect of professional practice costs
Given both the necessity of courage for good clinical practice and the dangers of heroic blindness, bioethics MUST consider carefully the nature of “clinical courage.” Clinical cowardice, for example, may be in play when a clinician simply avoids a difficult conversation either by not having it at all or by bulldozing through it in order not to have to see the effects of the blundering words. Similarly, it may be cowardice that leads a clinician to use the reality of insufficient information and unpredictable outcomes as reason to insist on continuing a course of treatment that seems clearly futile and even inhumane. Foolhardiness can also take many forms. Courage is the virtue of approaching realistic fears or threats with appropriate confidence. It is not unwarranted certainty, bravado that disregards danger, or the rash offering of an empty hope. It is not blindly overconfident bluster that wades into difficult conversations or risky situations without caring to see how much harm is done, or how inept the performance, or to learn how to do it better.20 Courage is a complex virtue, not an easy, mindless charge forward
and how it may best be supported are questions worth bioethicists’ best efforts. The case against courage. The kind of “moral courage” being called for in recent literature, especially in the field of nursing,21 is, however, quite another matter. For the most part, it is being touted as the antidote to moral distress, as the virtue required of a clinician who chooses to speak out against what he believes to be moral error and must do so in the context of fear—fear of some sort of retaliation, on the one hand, and fear of loss of personal integrity on the other. There is no question that what is being called for is indeed courage; the fears, unfortunately, are too often realistic. The problem lies in valorizing that courage, as though it, too, were essential for good professional practice and even for one’s own wellbeing, despite the obvious toll it takes and despite the fact that the situations calling for courage could—and should—be otherwise, unlike the H AS TI N GS C EN TE R RE P O RT
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clinical encounters discussed above. It is a fundamental error to assume that the courage needed for a particular clinician to request an ethics consultation in a rigidly hierarchical hospital is as unavoidable and as definitive of good health care as the courage needed to carry out well the responsibility of telling parents that their infant daughter is dying. Clinicians can experience negative consequences associated with courage whether they act courageously or find it impossible to do so. This “dark side” of courage is exemplified in a study, by Elisa Gordon and one of us (Ann Hamric), of nurse access to ethics consultation services.22 Twice as many nurses wanted to call for an ethics consultation as actually called. In exploring the reasons for this disturbing pattern, the study found that nurses expressed moral distress at their inability to act on their ethical obligations to their patients. They reported a significantly higher perceived level of risk in the situation than did nurses who called for a consultation, and they experienced significantly higher regret than did nurses who obtained a consultation, regardless of consequences. One nurse who did not call for a consultation, ostensibly because there “really wasn’t time,” stated, “You know maybe there was enough time. And I didn’t realize I had that avenue. And I don’t know if it was because [one parent] was a physician in the hospital, politically there was just—I don’t know. But I was so berated in that situation, I didn’t have enough courage to then, you know, I just was like, okay, I’m wrong, I’m bad, that’s it” (p. 245). This nurse not only blamed herself for her lack of courage but also went on to criticize her own character. The moral residue expressed in many of the nurse narratives elicited in this study had persisted for years. Because these nurses believed they knew what they should have done ethically but were unable to act—the definition of moral distress—and because these situations occurred repeatedly, they experienced both 38 HASTI N G S C E N T E R R E P ORT
significant moral distress and the moral residue buildup that Elizabeth Epstein and one of us (Hamric) have characterized as the Crescendo Effect. 23 There are already enough root causes of moral distress without adding “lack of courage” to the list. The painful experiences described by the nurses in this and countless other studies resulted from the dysfunctional systems within which these nurses worked, not from character deficits. The power of this moral residue was underscored by one study participant who refused to allow her story to be included in the findings in spite of the authors’ disguising most of the features of the case to prevent identification. In her final comment, she said, “They [her institutional leaders] will know it was me, and I need to work here.” The case in question was five years old when this nurse refused to let it be used. Conversely, providers who do act courageously can also experience negative consequences. In the Gordon-Hamric study, nurses who exhibited courage were often ostracized by other team members. They experienced alienation in communications with team members who felt that they had gone above their level of authority in calling for an ethics consultation. They endured angry reactions from colleagues (particularly physicians) and were even threatened with loss of their jobs. In situations requiring courage, providers have a strong sense of isolation that is the antithesis of effective team communication. Requiring the exercise of courage can perpetuate dysfunctional teamwork as teams become polarized and relationships strained. Courage always comes at a cost, as we’ve said, but this is an unacceptable and unnecessary price. It should be clear that exercising courage is not sufficient to address moral distress in dysfunctional systems and certainly should not be seen as a “magic bullet” to eliminate moral distress. Although clinicians may honor their own moral agency in taking courageous action in the face of
unethical practice, such action alone will not deal with the unit and institutional levels at which moral distress operates.24 Lisa Tessman laments that “there is a level of courage that is needed only for facing what no one should have to face.”25 She argues that virtues that seem to be called for and praiseworthy under conditions of oppression are “burdened” because, although they may serve well the oppressed group’s survival within and subversion of those conditions, they cannot contribute to the individual virtuous person’s flourishing, contrary to the Aristotelian definition of virtues as primarily doing just that. If it truly takes courage—that is, if the fears of retaliation and harm are realistic—for a nurse, a resident physician or medical student, a pharmacist or social worker, or anyone not in the top rank of the hierarchy in a medical center to question the way things are done or to speak up for what they believe to be right, then conditions of oppression exist, and Tessman’s analysis is telling. Tessman lodges several complaints about invocations of courage. One is that the call for courage, under oppressive conditions, is constant; there is no break from having to consider putting oneself in harm’s way in order to maintain integrity. This is a significant stress added on to all the other, truly inescapable stresses of a life in health care; it is surely difficult enough that clinical care itself requires courageous professionals. Another, related problem is that an emphasis on courage deflects attention and siphons energy away from other virtues that need cultivation and expression—virtues like wisdom, compassionate caring, and justice— and away from the human relational calls of daily situations, the need to be fully present for and with others (not incidentally, contributing to the sense of isolation noted earlier). In a similar vein, Amélie Rorty cautions us that the promotion of courage may result in the tendency to misconstrue encounters as nothing more than May-June 2015
opportunities for its display. She says that a person intent on being courageous “tends to interpret situations as presenting obstacles to be overcome, seeing situations as occasions for confrontation and combat. . . . The confidence that is part of courage tends to dampen imaginative foresight directed to avoiding oppositional confrontation.”26 This overemphasis on courage can result in precisely the distortions of courage that Aristotle warned against, perhaps especially foolhardiness. The “courageous hero” may fail to appreciate what should be appropriately feared in the situation, such as further shrinking of one’s capacity for compassion or coming another step closer to burnout and a loss of vocation. The “courageous hero” may become overconfident of her grasp of the situation and fall into the traps of moral arrogance and certitude. Although much of the recent literature on courage warns that these traps must be carefully avoided, the promotion of such courage may lead the clinician straight into them. Valorizing courage that is required only because of unethical institutional structures seriously risks promoting a diminished level of patient care as well as a diminished level of collegiality and vocational satisfaction. Insistence on courage in everyday practice implies that conditions of fear, danger, or risk are omnipresent and that a provider cannot be ethical without courage. Within moral and just institutions, many if not most caregiving situations should not require courage beyond what may be inseparable from good care of patients, as discussed above. Any invocation of the need for individual provider courage outside those limits should be coupled with careful investigation into systems and cultures of practice to ensure that they are ethical environments that promote doing the right thing. Research on moral distress reveals that these systems and cultures can foster recurring situations that challenge a provider’s moral integrity. Focusing on the moral virtues of May-June 2015
individual providers is only one part of creating more ethical practice environments and may be ineffective if power hierarchies and dysfunctional systems remain unchanged. One author went so far as to say that we need to build environments that support courage.27 In our view, the opposite is true: we need to build settings where courage is rarely needed to do the right thing and practice ethically. Mounting data show that ethical work environments are good for patients and providers alike. If health care professionals are routinely required to exhibit courage to survive their practice in an institution, this should be a source of concern, not celebration. Courage should not be necessary for any pro-
and discernments—when promoted as both necessary and unproblematically virtuous, may feed a “hero’s” inclinations toward moral arrogance and certitude but will do nothing to correct the fundamental injustice of hierarchical structures of power, position, and gender that continue to silence the moral voices of engaged participants. As long as courage is necessary to practice the medical professions well—and it will be necessary as long as people get seriously ill and die— then it is important to recognize it, name it, encourage it, and reward it. The challenge is to look beyond the nobility of the courage called for by the nature of caring for the sick in order to see the damage inflicted by
Courage should not be necessary for any health care professional to ask a question or make a suggestion regarding a patient’s care. fessional to ask a question or make a suggestion regarding a patient’s care. The implications of such excessive valorization of courage are significant. Are we to build this expectation into professionals’ job descriptions? Should we fire providers who are unable to be courageous in the face of significant risk? Such expectations are problematic to measure, and such actions difficult to justify in ways that stand up to objective scrutiny. Making heroes of those who behave courageously in relation to their institution and its hierarchies avoids the question of what is being done to relieve the conditions of oppression. Oppressive conditions—unresponsive systems, bullying clinicians, job insecurity, and the like—may be tolerated not only as unalterable but even as acceptable because they nurture desirable practices of courage. The kind of courage needed only for facing what no one should have to face—the possibility of real and significant harm if one expresses or acts on one’s best moral instincts
calls for courage that are not so entailed and to then work (courageously) to diminish the latter call. To be sure, courage should be celebrated. But demanding individual courage is no substitute for institutional justice. In Remembrance
John Arras died shortly before we received the proofs of this article. Collaborating with John, whatever the project or conversation, was always an intense and joyful adventure: stimulating, challenging, rigorous, and fun. We treasure our memories and mourn our loss of a beloved friend and inspiring colleague. Notes
1. See, for example, E. Pellegrino and D. C. Thomasma, The Virtues in Medical Practice (New York: Oxford University Press, 1993); Daniel Sulmasy, “Should Medical Schools Be Schools for Virtue?,” Journal of General Internal Medicine 15, no. 7: 514-16. 2. C. V. Caldicott and K. Faber-Langendoen, “Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third-Year Medical Students,” Academic Medicine 80 (2005): 866-73; V. D. Lachman et al., “Doing the Right Thing: H AS TI N GS C EN TE R RE P O RT
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Pathways to Moral Courage,” American Nurse Today 7, no. 5 (2012): 24-29; J. S. Murray, “Moral Courage in Healthcare,” Online Journal in Nursing 15, no. 3 (2010). 3. Lachman et al., “Doing the Right Thing,” 25. 4. J. O. Urmson, “Saints and Heroes,” in Essays on Moral Philosophy, ed. A. I. Melden (Seattle: University of Washington Press, 1958), 198-216, at 206. 5. I. Kant, Groundwork of the Metaphysics of Morals, trans. H. J. Paton (New York: Harper and Row, 1964). 6. This is not to suggest that utilitarians view the personal welfare of health professionals to be irrelevant. It is, rather, always subject to being overridden by countervailing social benefits. 7. Philosophers of both utilitarian and Kantian persuasions would most likely respond that their preferred moral theory is capable of accounting for supererogatory action with a bit of theoretical tweaking. We have found such attempts to be unconvincing, but this is not the place to argue our case. 8. Aristotle, Nicomachean Ethics, 1115b25. 9. For a robust defense of Aristotelian courage as an instance of practical reason, see D. Walton, Courage: A Philosophical Investigation (Berkeley: University of California Press, 1986), 59.
10. Aristotle focused on the threat of death in battle; see Nicomachean Ethics, 1115a25. 11. Time Magazine, “Person of the Year 2014: Ebola Healthcare Workers,” at http://www.time.com/ time-person-of-the-year-ebola-fighters. 12. American Nurses Association, “Justice Is Served: Texas Physician Pleads Guilty: ANA Gratified by Convictions in ‘Winkler County’ Nurses Whistleblower Case” (press release), November 8, 2011, http://nursingworld.org/FunctionalMenuCategories/ MediaResources/PressReleases/2011-PR/ Justice-is-Served-Texas-Physician-PleadsGuilty.pdf. 13. Aristotle, Nicomachean Ethics, 1115b20. 14. Ibid., 1106a5. 15. Some contemporary virtue theorists have discerned a tension or perhaps even a contradiction between Aristotle’s definition of virtue as a mean between extremes and the possibility of supererogatory action. How is it, they ask, that virtue is always a mean, while supererogation goes well beyond the mean in pursuing a good objective? Although the tide of contemporary scholarship seems to run against our position on the ultimate compatibility of supererogation and the doctrine of the mean, we are content to let this controversy play out in the virtue ethics literature while clinging, albeit tenuously, to the traditional view.
6.
16. Aristotle, Nicomachean Ethics, Book
17. Ibid., III.6. 18. L. Tessman, Burdened Virtues: Virtue Ethics for Liberatory Struggles (New York: Rowman & Littlefield, 2005), 125. 19. M. U. Walker, “Moral Luck and the Virtues of Impure Agency,” in Moral Contexts, M. U. Walker (New York: Rowman & Littlefield, 2003), 21-34, at 26. 20. Philosopher Amélie Oksenberg Rorty offers a particularly cogent discussion of the seductive attractions of “heroic” blindness, misread as virtue; A. O. Rorty, “The Two Faces of Courage,” Philosophy 61 (1986): 151-71. 21. Lachman et al., “Doing the Right Thing”; Murray, “Moral Courage in Healthcare.” 22. E. J. Gordon and A. B. Hamric, “The Courage to Stand Up: The Cultural Politics of Nurses’ Access to Ethics Consultation,” Journal of Clinical Ethics 17 (2006): 231-54. 23. E. G. Epstein and A. B. Hamric, “Moral Distress, Moral Residue, and the Crescendo Effect,” Journal of Clinical Ethics 20 (2009): 330-42. 24. Ibid. 25. Tessman, Burdened Virtues, 127. 26. Rorty, “The Two Faces of Courage,” 154. 27. Murray, “Moral Courage in Healthcare.”
Another Voice Practitioner Courage and Ethical Health Care Environments by justin oakley
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n “Must We Be Courageous?,”1 Ann Hamric, John Arras, and Margaret Mohrmann highlight how contemporary accounts of the virtue of courage in health care often gloss over deeper problems in the underlying health care systems themselves. They express particular concerns about the appropriateness and personal costs of exhortations to health professionals to take courageous action in circumstances where this is “required only because of unethical institutional structures” (p. 39). For instance, inadequate whistleblowing protection procedures leave clinicians exposed to unnecessary risks
Justin Oakley, “Practitioner Courage and Ethical Health Care Environments,” Hastings Center Report 45, no. 3 (2015): 40-42. DOI: 10.1002/ hast.454
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when reporting patient harms caused by clinician negligence or when speaking out against workplace bullying. The shortcomings of such procedures are unfair to individual practitioners when the onus is left on them to see that patients and colleagues are adequately protected. The failings of such systems are also unfair to the community, since relying in such ways on the extraordinary personal qualities of rare individuals risks distracting regulators’ attention from the underlying systemic issues. Hamric, Arras, and Mohrmann also bring out well how relevant background factors implicated in such harms can be overlooked by other approaches, such as utilitarianism, which tends to advise clinicians to respond well to present harms without necessarily investigating what caused a situation to become so dire in the first place. May-June 2015
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