Original article

doi: 10.1111/nup.12063

Virtue ethics and nursing: on what grounds? Roger A. Newham DMedEth Senior Lecturer, Society and Health, Buckinghamshire New University, London, UK

Abstract

Within the nursing ethics literature, there has for some time now been a focus on the role and importance of character for nursing. An overarching rationale for this is the need to examine the sort of person one must be if one is to nurse well or be a good nurse. How one should be to live well or live a/the good life and to nurse well or be a good nurse seems to necessitate a focus on an agent’s character as well as actions because character is (for the most part) expressed in action (e.g. see Laird). This paper will give an overview of the reasons for the role and importance of character in nursing practice and explain its relation to nursing’s frequent use of virtue ethics in order to recommend caution. While the paper agrees that the role of character is important in nursing caution is needed in both how much moral and thus normative, emphasis is being placed on the psychology of character and on the drift to virtue ethics. The psychological which may be explanatory needs to be linked with the normative, and a justification for the normative is needed. A justification as virtue ethics is contested, and nursing practice does not need to take on this explanatory and justificatory burden. A tentative proposal raised but not discussed in depth in this paper is that when an ultimate explanation or explanatory ground is needed, nursing practice leads quite naturally to a form of consequentialism as well as a realist metaethic. On this account, there are two levels of moral thinking, and nursing practice entails the virtues at one level and leads quite naturally to moral thinking at another more critical level of the criterion of what makes something right and good independently of character. Keywords: phronesis, moral theory, agency.

Correspondence: Dr Roger A. Newham, Senior Lecturer, Buckinghamshire New University, 106 Oxford Road, Middlesex, London UB8 1NA, UK. Tel.: 01494 522 141 ext 4431; fax: 01494 522 141 ext 4431; e-mail: [email protected]

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Introduction Within the nursing ethics literature, there has for some time now been a focus on the role and importance of character for nursing. An overarching rationale for this is the need to examine the sort of person one must be if one is to nurse well or be a good nurse. How one should be to live well or live a/the good life and to nurse well or be a good nurse seems to necessitate a focus on an agent’s character as well as actions because character is (for the most part) expressed in action (e.g. see Laird, 1946). This paper will give an overview of the reasons for the role and importance of character in nursing practice and explain its relation to nursing’s frequent use of virtue ethics in order to recommend caution. While the paper agrees that the role of character is important in nursing caution is needed in both how much moral and thus normative, emphasis is being placed on the psychology of character and on the drift to virtue ethics. The psychological which may be explanatory needs to be linked with the normative, and a justification for the normative is needed. A justification as virtue ethics is contested, and nursing practice does not need to take on this explanatory and justificatory burden. Though nurses are ‘doing moral theory’ when they examine issues in practice, such as truth telling (MacIntyre, 1984), for the most part, the work of nursing is clearly moral by any theoretical light. However, nurses can and should give substantive reasons, when they need to, for what they do, and for the most part, these can be given fairly easily without recourse to an explicit, ultimate ground. However, where giving reasons for practice proves difficult to do, traditional moral theories, unlike virtue ethics, provide an objective ground for reasons. They provide criteria of what makes something good or right, or virtuous. That is, they can provide an account of both character and normativity. They can also accommodate a virtue theory and the idea of phronesis and so accommodate the importance of character while recognizing that there is something the phronimos, and thus, having moral character as virtue gets right. Having a good or virtuous character and having phronesis does not make things right or good.

© 2014 John Wiley & Sons Ltd Nursing Philosophy (2015), 16, pp. 40–50

A tentative proposal raised but not discussed in depth in this paper is that when an ultimate explanation or explanatory ground is needed, nursing practice leads quite naturally to a form of consequentialism as well as a realist metaethic. On this account, there are two levels of moral thinking, and nursing practice entails the virtues at one level and leads quite naturally to moral thinking at another more critical level of the criterion of what makes something right and good independently of character.

An overview of character and nursing practice Nurses usually care for or/and about ill and especially vulnerable people and that such caring is related to both the character of the nurse as well as actions and that both are moral concerns. Nursing is claimed to be a moral profession, and the good and excellent nurse is or must be a good and moral person (Pellegrino & Thomasma, 1993; Connor, 2004). To be such a person necessitates a focus on character. It is said that a greater focus on the agent and character than has been given in traditional moral theories (or at least by theorists) is needed for nursing to be effective. At a very general level, to be effective in nursing is to provide a ‘holistic’ form of health (Whelton, 2002; Armstrong, 2007). This may form nursing’s ‘function’ or end for which good character and virtues are necessary to achieve excellence (Pellegrino & Thomasma, 1993; Begley, 2008). More specifically, to be effective includes such thing as being able to form therapeutic relationships with patients that includes listening to narratives of their illness (Armstrong, 2007) and understanding (in some sense) their emotions (Scott, 2000). Ekstrom (2012) has an insightful discussion about this based on a medical case study about how a lack of compassion, a fault in the agent’s character, can result in poor medical treatment and disastrous outcomes. Like current UK, nursing she calls for the need for educational improvements to encourage and thus improve character. Ekstrom is actually writing about the need for the virtue of compassion as the disposition to experience the emotion of compassion at the right time and towards the right ends etc.The compassionate person has an ‘effective impulse’ leading a

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person to assist in the recognized suffering of another (ibid., my emphasis).Two things are important to note. One is the claim that nurses need education in compassion. The type of education is plausibly not meant to be theoretical but habitual in a sense to be explained below in relation to the virtues. The second thing is that on this account, one cannot experience compassion if one does not believe the agent is suffering, and one needs humane engagement to enable this, such as listening to the patient’s narrative and making sense of their expressed emotions. However, what takes priority here, the belief that someone is suffering or the emotional experience? In Ekstrom’s case study, one set of doctors did not believe in the stated symptoms and thus did not believe the expressed emotions. The doctors who did were very highly specialized and whose knowledge meant they did believe the symptoms and so did believe the expressed emotions. The case study does not show by itself that one set of doctors provided humane engagement as displaying emotions and not the others or that it was humane engagement as a display of emotion that made the difference rather than beliefs. Further, as just mentioned, the case study was about the virtue of compassion not a mere feeling or emotion. This makes a difference, and it may be that the virtue of compassion includes the emotion or feeling only slightly if at all (Crisp, 2008). This may not seem to detract from a focus on the agent’s character as having the virtues is still part of one’s character. A reply is that this is true but that much of the resurgence of interest in virtue is the idea that it accommodates a person’s emotions. Another reply is that the need for emotions as part of one’s character is also meant to be a moral one; they are a part of what it is to have a good character needed to get things morally right. A further need for character in nursing has to do with the point that (moral) principles and (moral) rules do not apply themselves; it takes moral agents to do this with an awareness of the particulars of the situation, and so, it is crucial to examine the sort of nurse, one which means examining their character (Armstrong, 2007; Begley, 2008). The need (necessity?) for good character has something to do with both motivation and an ability to get things right in practice. There is a sort of ‘internal imposition’ of the

agent who is a nurse such that he reliably as characteristically tells the truth, is patient with patients, and will do and be so when no manager or relative is around to observe (Pellegrino & Thomasma, 1993; Begley, 2008). So, a general idea is that the virtuous person is motivated to act reliably. One way to explain a sense of reliability which seems to bring out nicely the need for character is in relation to trust. However, it also points out a problem. The notion of reliability implies some degree of trust in the nurse by patients especially if there is a knowledge gap and the patient is particularly vulnerable. It may be claimed patients are ‘forced’ to trust or to at least rely on the nurse and that such reliance may just be the patient taking a rational but calculated risk in the situation. Trust can however be understood more as an emotion, as an ‘effective attitude’ (Lahno, 2001) and so not subject to direct, rational control. The way one sees the world, a seeing as, is effected by the emotional attitude. Different attitudes to seeing the world can result in different actions (ibid.). But a problem looms. What if the nurse’s attitude differs from the patients? The nurse will see the world differently. In response, it can be claimed that it is virtue we are talking about, and to be a virtue means getting the action and feeling right. I think this does not solve anything, and it will be discussed further below though it is connected with the next thing about the need for character in nursing practice the idea of getting things right. What is the knowledge, as getting things right, needed for nursing work? The ‘work’ of nursing includes the knowledge of nursing and its practice in particular situations. On this moral and ‘particularist’ account, knowledge may be praxis (good action) rather than poesis as technè (production) (Connor, 2004). Perhaps a minimal level of competence for a nurse is to have technè, such as being competent in the technique of using a blood pressure machine, but praxis is needed to be a good nurse or an excellent nurse; using the machine well on and with a particular patient at a particular time. Something that cannot be learnt in a classroom nor even be completely taught by instruction and of which there is no end to the learning (hence, the concern raised above about claims for the need for the education of nurses in emotions such as compassion). In

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short, praxis is a different type of rationality for action or at least an extension of how the term is commonly understood roughly as scientific cause and effect and useful for prediction and control of nature. On such an understanding, problems can be anticipated and thus planned for in advance, being contained in the general formulae and just needing application (Dunne, 1999). Objective, technical rationality means the role for judgement is minimized and possibly even ideally dispensed with (ibid.). But praxis requires judgement of the particular bringing in application of the general as and when required. The notion of praxis as excellence resonates with Aristotle’s phronimos and hence the link (again) with good character and or as moral virtues especially in order to get things right (or act well). Not just anyone can get moral matters or actions right unlike (it is claimed) learning maths or a scientific formulae where once you have had some technical training, a young child or murderous criminal could become an ‘expert’ (Hursthouse, 2011). It is necessary to emphasize the term moral because the particularist claim used in nursing is generally about moral actions citing McDowell’s (1979) use of Wittgenstein’s rule following problem, but Wittgenstein’s point is about all rules (Crisp, 2000). This point lessens the force of a version of a particularist claim that moral knowledge is different in type to other forms of practical knowledge. So knowledge of nursing practice could be both moral and nonmoral and still require judgement. Aristotle’s analogy of virtuous or moral knowledge with medicine however does make such a distinction; medicine is a technè not praxis. Perhaps it is almost praxis and perhaps it could be argued that to practice medicine well or excellently needs praxis as morally good action. If nursing knowledge is praxis, then character as having virtue seems to be necessary for an openness to learning which moves beyond experience (ibid.) and towards good action. Good action as character as virtue seems to be necessary for nursing practice. This is important in that from what has been said so far the need for good character seems clear but not the sense of good or morally good.The next section will examine how character is related to virtue which will lead naturally into a distinction between virtue ethics and virtue theory regarding the morally good.

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Character and virtue The notion of character used in many accounts of virtue is a fairly technical one involving a number of interrelated ideas. The character relevant for being virtuous is (ideally) something that is a fixed and permanent disposition or state (Aristotle tr. 1980; Hursthouse, 1999). The settled state of one’s virtuous character comes, if it does (it is plausible that Aristotle did not hold out much hope for most of us who need the rule and enforcement of law), only after many years of adulthood and also being brought up ‘correctly’ or well (Burnyeat, 1980). What one learns is at first through rote and following ‘moral exemplars, learning “the that” and eventually one learns “the because” ’ (Burnyeat, 1980). Understanding the idea of ‘the because’ is a crucial issue for this discussion, and it leads directly into the next section about virtue ethics and virtue theory, so more will be said there. But for now, one point to note about the relationship between character and virtue as a settled state to indicate a sense of ‘the because’ is useful. Having the virtue of say honesty seems mean that for instance, a tradesman (or nurse) would not cheat or be dishonest if it appeared it would make a profit. But this understanding of the character trait of honesty would I think still be or show an honest character if the tradesman (nurse) knows that honesty is a good business (nursing) asset (Laird, 1946). For Aristotle and Hursthouse among many others, the fixed and permanent disposition or state of virtue entails (in some sense of entail, probably not logical) acting (being in a certain state) and feeling (including the emotions and desires). Having character as virtue includes emotions, and nursing practice makes much of the appropriateness of the emotions to nurse well or excellently (Scott, 2000). The understanding of the appropriateness of the emotions is vital but a very difficult one to grasp, and this is discussed below under virtue ethics and virtue theory but it is clear that some virtues can be primarily characterized in terms of emotion and others primarily of action (Laird, 1946; Crisp, 2010). A character trait to be a virtue rather than a vice disposes one to act rightly, hence the idea of ‘moral character’ or moral character traits (Brant, 1970).

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Some accounts of virtue would deny a role for deontic concepts (Armstrong, 2007), but it is unlikely that the sense of right and ought would change (Crisp, 2004). The doctrine of the mean shows how both actions and feelings are involved in the idea of getting things right, as acting virtuously, and it can highlight the complexity of morality with many things to get right including the emotions; there are many ways also to go wrong (Crisp, 2010). So, when character is understood as virtue, it automatically involves having good character as well as getting things right in practice. Though the fully virtuous person, the phronimos, with a settled state of character (by definition) gets things right and possibly sets an epistemological standard, she does not make things right. What does make things right can be explained in both normative theory and metaethics.

Virtue ethics and virtue theory Within the nursing ethics literature, the reasons for the resurgence on the role and importance of character often follow the same themes in moral philosophy which claim that within traditional moral theories (understood broadly as especially based upon Mill and Kant), there has been a lack of the importance of character as well as agent relative concerns and that moral theory needs to reclaim them (e.g. see Trianosky, 1997 and Athanassoulis, 2013 and for a nursing ethics focus Armstrong, 2007). Nursing may have specific aims, requiring good (moral) character for being a nurse or at least for being a good nurse, but ultimately, such aims are of a moral nature, and so, at this general level, the link with the themes in moral philosophy are not wrong. As discussed above, the idea of character is taken to be closely linked with the virtues, and the debates within moral philosophy include how character and virtues can be (and have been) accommodated by consequentialist and deontological theories as well as a development of a third type of theory, virtue ethics. Virtue ethics may still be thought of as a term of art because there are varieties of virtue ethics (Walker & Ivanhoe, 2007). Though there are varieties, an important general distinction can be made between virtue ethics and virtue theory (Driver, 1996; Armstrong,

2007; Athanassoulis, 2013). Roughly, the former (especially in a pure, monistic form) is a normative theory where rightness is defined in terms of, or just is, virtue but not vice versa, and the latter is an account of the role virtues have in a particular normative theory. A better distinction between virtue ethics and virtue theory can be made following Crisp (2010) via two levels of normative theories: substantive and explanatory. The former is about how one should live and the latter why one should live that way. An explanatory virtue ethics would need not only to say ‘lead the life of virtue’ but also the ultimate reason or (non derivative) grounding reason for doing so should be provided by virtue (ibid. p. 23). Crisp (2010) in a footnote makes a very helpful clarification about such grounds that the virtue of an act itself counts in favour of the act.Though this can helpfully distinguish a virtue ethics from virtue theory, as Crisp points out, it leaves open which character traits count as the virtues. This proves to be a particular pressing problem for virtue ethics which must rely on character.What character traits constitute a virtue? How can we validate our beliefs as to which character traits are virtues? This seems especially pressing if emotions are part of what we need to get right. Burnyeat’s (1980) account of how one develops or learns to be virtuous the notion of ‘the because’ which comes after the habitation as ‘the that’ within virtue ethics is not meant to be independent from virtuous character as it could be in an objective goods account. A virtue ethics understanding of the development of character traits such as kindness and kind outcomes for instance is valued because it is part of virtue (Athanassoulis, 2013). So although at a general level of abstraction this distinction between virtue ethics and virtue theory seems correct, defining virtue ethics is much more complex than this division suggests (Swanton, 2013). In part, this is because virtue ethics must have an essential reference to virtue as an enduring state of a person’s character and different accounts of virtue ethics differ on what sort of character is to count as a virtue. The difficulty in giving an account of a virtue ethics in general is reflected in the nursing ethics literature about the need for a focus on character and virtues. Some, such as Armstrong (2007), explicitly claim to be

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using a ‘strong’ virtue ethics, probably not a pure monistic account but an explanatory virtue ethics and as a distinct normative theory. Armstrong’s (2007) book-length study of the virtues in nursing practice spends a chapter discussing the problems for ‘traditional’ moral theories and the rest expounding the advantage of a virtue ethics approach specifically for nursing practice.Though he makes a great use of Aristotle to support his claim of the need for a virtue ethics for nursing, it is contested as to whether Aristotle should be so used (Buckle, 2002). Notably, this strong version as virtue ethics claims the justification of acts is ‘couched’ in virtue terms (Armstrong, 2006, p. 118). So, acts somehow are justified by character traits of agents as virtues. Psychology seems to be justifying and not just explaining actions. But it can be questioned if Armstrong’s account is really a virtue ethics (ignoring the question of the use of Aristotle as holding a virtue ethics). His approach follows Hursthouse and MacIntyre. He follows Hursthouse (1999) especially in critiquing other moral theories but also her (Anscombian) use of virtue rules to provide action guidance and characterization of the virtues in terms of an agent’s character traits. But Hursthouse does not justify acts by an agent’s character. The theory (the last third of the book) does appeal to an objective account of the good on which the virtues depend, and she admits her account of right action is ultimately (though perhaps not viciously) circular (see Hursthouse, 1997 footnote 2 and Begley, 2005) and that many virtues depend on the idea of the good. Armstrong uses MacIntyre’s (1981) After Virtue account of internal goods for nursing practice which seems to be ultimately independent from character or suffers from moral relativism as the later MacIntyre admits. So, Armstrong’s virtue ethics could be understood as a virtue theory with perhaps explanatory and justificatory benevolence. I think he would deny this, based (in good part) on implications from his critique of traditional normative theories and claim that character and virtue cannot be really understood by them. But here lies a real issue, apart from his claim about justification, the rest of the support for a virtue ethics is based on issues to do with decision making including motivation, emotions, beliefs, etc., all things which do involve the

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agent and in some sense his character. But these are things which, despite Armstrong’s criticism, traditional theories can and do take account of, plausibly to the right extent. Begley, calls her approach variously virtue based (Begley, 2008) and virtue centred (Begley, 2005), claiming it is midway between a radical replacement version (a virtue ethics) and a supplementary account. So, it is actually unclear if Begley’s approach is a virtue ethics or virtue theory, but it is likely to be a virtue ethics because of the dissatisfaction with traditional normative theories for nursing. A particularly important aspect of virtue ethics is the character of the virtuous person who behaves well consistently and has a disposition to do so (Begley, 2008, p. 338). Even if a virtuous person does not know the rules, he will still not do bad things because of his disposition to act well (ibid., my emphasis). Much or indeed everything hangs on this idea of acting well/rightly because of one’s disposition (or trait). The connection between not acting badly and one’s disposition is not a necessary connection. The idea may be plausible if not knowing is meant as not explicitly citing rules or giving reasons at the time of acting and so a sort of tacit knowledge or ‘habitual’ as ‘second nature’ action (where habit is not mindless repetitive action or reaction), but there must be something recognized as good that guides his action and provides an account of what makes an action normative. While it is stipulative or true by definition that a practically wise person will not act badly or get things wrong, it must be ideal because of the contingent human nature, and even for such a phronimos, there must be something that is right the phronimos does not make it right. If this is near correct, then this need not trouble an explanatory consequentialist and substantive virtue ethics, providing the necessary account between psychology and the normative and ultimate justification. The psychology as character includes beliefs and emotions. There are two particular issues related but ultimately distinct. One is about the need for or the prominence of the emotions or affect in virtue as getting things right morally. The other has to do with the relation of a human being’s psychology generally as beliefs, desires and emotions and how they link with normativity. Emotions are meant to be under-

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stood to be more than instinctive reactions to independent facts or situations. They are meant to actually affect the understanding of situations or certain (types of) facts. So, emotions are on this account necessary for (full) understanding of moral issues; they are a necessary causal part of full understanding (Starkey, 2008) or conceptual part of full understanding and awareness (McDowell, 1979; Wiggins, 1980). One’s emotional awareness of an object say is unique to the emotional state and different from an unemotional awareness of the object (Starkey, 2008). So, an experience of an event with an accompanying emotion may change the experience of the state of awareness of the event itself and as result of this procedure produce an understanding of the event that is not possible without the emotion.

(Starkey, 2008, p. 430)

Starkey’s account of the necessity of the emotions for virtue and character involve a cognitive and affective element. Neither on its own is sufficient for understanding character for ethics, but what the relationship should be is much contested. Starkey distinguishes what he calls apprehension from belief states and perceptual states so that the emotional apprehension is phenomenal, a sort of ‘seeing as’ and yet it does not, or rather is not meant to, support emotions as noncognitive. But it is unclear how they can be what he claims they are and be cognitive. A phenomenal account of ‘seeing as’ is different from a reflective judgement that something is the case or is good. It is more likely that the emotion as noncognitive feeling provides motivational support for the cognitive judgment. But what we are after here is how emotions support the cognitive and objectivity as getting things right and how such phenomenology relates to rationality and reality. Starkey’s claims are like much earlier discussions about the rationality of the virtues. On a virtue ethics account, one’s character is part of having desires and beliefs such that rationality in virtue ethics is to be understood as denying a distinct separation of the rational with beliefs and nonrational with desires (McDowell, 1979; Hursthouse, 1999). However, on Starkey’s (2008) account, the idea of awareness and understanding can diverge as when one knows a snake is not dangerous but one’s awareness is one of

fear nevertheless. What is the feeling of fear adding to the knowledge of the situation? Explanations may be given regarding evolution and survival, but what we need is normative as getting something right and acting as one ought. Full understanding comes when awareness and understanding converge with an appropriate understanding of the situation (Starkey, 2008). This or a similar sense of appropriateness for value is vital but a very difficult one to grasp in the literature by McDowell and Wiggins, both of whom are frequently mentioned in the nursing literature as providing support for virtue ethics. When trying to avoid subjectivism and relativism, Wiggins labels his account ‘a sensible subjectivism’ (Wiggins, 1987) and McDowell (1979) relies on a ‘whirl of organism’. Starkey (2008, p. 440) I think also leaves the problem of relativism hanging when he claims that the criteria of appropriateness include ‘our larger values, interests, concerns and goals (i.e. things that relate to our thriving)’. Starkey unlike McDowell and Wiggins admits that it is not a conceptual question as conceptually full understanding need not necessarily include emotion but it seems to be shown empirically. But whether causal or conceptual, an account is needed of how the account of character which includes emotions or sentiments necessary for virtue can be cognitive and objective, avoiding relativism. In fact, the account is likely to need to be conceptual because of the way empirical studies must collect their data. Such studies might (though it seems likely that so far they have not) explain a virtue ethics account of virtuous action but seem not to be able to justify it. Though an understanding of character dispositions or states, as referrals to the person’s moral character and the facts of their decisions, may help explain action by showing what (we think) the agent saw as salient at the time of acting, they cannot be used so easily by the agent to explain her own actions (Moreau, 2005) First, the agent himself will not, or should not, claim he is acting from say compassion because to do so will definitionally at least prevent him from acting on ‘true’ compassion. Second, from the agent’s perspective, it may seem too third personal to explain what he really was aware of to a third person in virtue character terms (Moreau, 2005).

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What is needed is something like reasons as facts belonging to objects so perceived. The account of the role and importance of character traits is as dispositions to respond to reasons other than facts about our characters.The normative force of disloyalty for instance does not seem conditional on anything you would do or feel or even desire (Moreau, 2005). For example, we are passive with regard to some nonmoral dispositions such as arachnophobia, which are just (brute) facts about how we tend to be moved, in a way in which we do not regard moral incapacities, and so they are not/cannot be input to deliberation. ‘I cannot do that, it would be disloyal’ are inputs and ones we expect reasons can be given, and such reasons cannot just be that it is a discovery about one’s psychology rather than the normative (ibid.). Hursthouse (1999) and Athanassoulis (2013) may stop too soon with their notion of virtue reasons as ‘the because’ of justification although Hursthouse does link them ultimately to notions of the good and gives an objective account of a ground for the virtues turning her account ultimately into virtue theory.

Some issues for nursing and virtue ethics The strong focus on the agent and character via virtues in virtue ethics is part of how phronesis is to be understood as neither purely cognitive nor purely conative, noninstrumental mediation between the general and the particular that needs experience and aesthesis (Wiggins, 1980; Hursthouse, 1999). The connection with nursing is that nursing’s rationality is based on this understanding of the necessity of (moral) character, aesthesis and phronesis which very commonly takes leave from Aristotle’s account of ‘moral’ psychology though not always his understanding of the ultimate good or final end for quite literally (right handed) man. Knowing what to do (acting rightly, well or good) on this account involves a sort of intuition and of necessity involves practical experience that need not rely on an algorithmic following of principles and rules, a form of praxis rather than technè and which by its very nature is impossible to articulate clearly and precisely in all of its rich detail (Newham, 2013). This may be especially so if the character traits of the

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virtuous person are a complex set of dispositions and that not all of what one knows can be ‘before the mind’ in intention (Wiggins, 1980).The idea of phronesis and praxis is well discussed in the nursing ethics (and education) literature particular with a focus on a restricted class of ends for nursing (Armstrong, 2007). The use of ends is problematic for virtue ethicists who do not subscribe to Aristotle’s metaphysics because ends are something distinct from the virtue, and it is particularly problematic for a restricted account of ends for nursing (Newham, 2012). There is a further problem with the way a (neo) Aristotelian use of phronesis can be understood which is particularly salient for this paper. The phronimos is an educational exemplar (Kristjansson, 2000), someone who helps us to learn how to think (Athanassoulis, 2013) rather than what to think. This use of the idea of a phronimos can be made by (almost) any moral theory especially in its connection with the emotions and character. As Hursthouse in 1997 stated the belief that there was some special link between the moral significance of the emotions, character and virtue ethics are likely to be a historical accident (Hursthouse, 1997, my emphasis). This is an important point to note as some excellent papers in the nursing ethics literature discussing the need for emotional sensitivity claim that it is ‘downplayed’ in traditional moral theories (e.g. see Scott, 2000). Much recent work in normative ethics is showing how there is a room for emotional sensitivity and so much hangs on what counts as too much downplaying and what counts as the right extent. But emotional sensitivity as moral perception (or awareness) as part of phronesis, it must get things right. What is right to do is not made right because of the phronimos; there is something that is the right thing to do in the situation and many ways to get it wrong, though by definition the phronimos cannot go wrong. So, although there are particularities and no algorithmic procedure to follow to determine or deduce the correct action and response, there must be something that counts as the right or good thing to do, and this is so ultimately irrespective of character. Normative moral theory provides ultimate reason, and some are founded on a moral realist metaethic. Phronesis is also intimately linked with the concept(s) of praxis and particularly as a knowing how.To

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know how to react and what to do requires aesthesis, and sometimes, this will need knowledge of particulars that only one very close to the person can know and plausibly over a long period of time. Stocker (1976) is a classic example of the idea of the need to act from virtue especially in intimate, personal relationships. The epistemic criteria of who is to be said to have a good character is extremely problematic generally (Vranas, 2009) and the narrower specification of good nurse adds further issues of differentiation in kind if not in ‘intensity’ from having a good character in general (Newham, 2012). Nursing as a profession draws a line of ‘professionalism’ distinguishing it from loving the patient or even friendship with the patient. Lack of such intimate particulars will affect one’s aesthesis and may mean that the agent gets the response at least not as good as it could have been but also perhaps wrong. In addition, part of the particulars will be the patient’s beliefs, wants, desires and emotions. The idea of a therapeutic relationship in nursing practice is linked to the idea of nursing’s knowledge and the need for virtue (Armstrong, 2006) and is linked to the previous point about how well the nurse needs to know the patient to provide such a relationship, but in addition, it needs to be remembered that the nurse is working with and for patients.As patients, there may well be a certain amount of bias on their part about the response required by a nurse as to how much and in what way nurses should care about them as well as for them. There seems little written about the idea of a virtuous patient though plausibly virtue ethics or a virtue account would apply to them as well as nurses. Noddings (2007) focuses strongly on the need for responses by the patient or cared for but denies these need be virtue responses.This could raise many issues in itself but particularly the idea of what is to count as appropriate response in particular situations, especially in a multicultural and morally pluralistic society which may throw into relief more frequently than homogenous society issues of moral conflict.

A consequentialist ground Within nursing, much of the time, things will run smoothly especially in day-to-day dealings with

others whom the agent need not know particularly well and when the moral reasons that matter are open to almost anyone to see (Lovibond, 2007), as are the technical facts for anyone who has had the relevant training. For a lot of nursing practice then, there will be an agreement on what to do and what should be done by all concerned, including the patient. This agreement is at one level pragmatic and intuitive in the sense of not needing to be critically thought through. Most in nursing and without can (and do) agree that nursing work achieves for the most part a specific aspect of the good life. Perhaps such agreement is all there is or at least can be for us human beings with our contingent natures, but I think nursing practice can deliver more, an appreciation of independent and morally realistic facts. The novice nurse may stumble over the technical but need not do so over the moral such as it is good this patient has his vital signs recorded where the good is understood as moral as well as technical. Following Lovibond (2007), some constituents of the world of value declare themselves more or less impartially to everyone, and though this is from a section recognizing that other aspects require judgement, much of everyday nursing practice is plausibly at this more or less impartial openness to all visitors and patients alike. A good deal of what this entails will be (the virtue of?) justice. Even where judgement is called for, where there is a breakdown of habitual everyday skilful coping (ibid.), all nurses are adults and have had some ethical formation, and it is plausible that for the most part, there can be an agreement in judgement in everyday nursing practice. However, there may be a disagreement at the critical level of what makes something right and good or the objectivity of morality, but because all agree in practice, it is not always directly relevant in practice to debate what this is. But when there is disagreement or even just reflection on practice and even in practice, it does become relevant and a virtue ethics seems to want for an objective criterion of morality/ moral facts that keeps it normative. In brief regard to deontological-type theories which also highlights the plausibility of a consequentialist (actually utilitarian as the article was written before Anscombe’s Modern Moral Philosophy),

© 2014 John Wiley & Sons Ltd Nursing Philosophy (2015), 16, pp. 40–50

Virtue Ethics and Nursing

Indeed, an agent ethics of the usual type tend to neglect its utilitarian potency and to concentrate its efforts upon the agent’s intrinsic worth. This may seem a little strange, not merely because the effects of a man’s deeds upon others really are important – for however vile a murderous hatred might be, its effects upon the victim cannot be regarded as negligible-but also because few moral excellences or defects are predominantly intrinsic, the great majority being primar-

practice and some theoretical study of ethics. The role of psychology (of the emotions and beliefs as one’s character) while possibly having some epistemic value needs steering by reason, and the reasons are there to be seen in the suffering and needs of patients, the alleviation of some of this being the work of nursing and the alleviation of a good deal more the work of ‘us’ as moral agents.

ily concerned with interpersonal human relationships. (Laird, 1946, p. 125)

Conclusion Nursing practice which usually necessitates good interpersonal relations seems plausibly to lead to a consequentialist ground and seems to lead naturally to a ‘dualism of practical reason’ or the critical and intuitive level of moral thinking (Star, 2011). Most, if not all, of what nursing practice entails is achieving good outcomes for patients; nursing’s day-to-day work generally meshes with intuitive judgements of what is morally good. The need for virtue theory and an account of human nature is important as well as the idea that human flourishing is good. But when nurses need to provide a ground for their judgements and actions, a consequentialist one seems most plausible. What makes an action good and what makes a trait of character a virtue (virtue theory) is the good effects it produces (Driver, 1996). Consequentialist theories tend to emphasize the gap between the critical standpoint and the intuitive (Hare, 1981; Driver, 1996; Crisp, 2010), but nursing practice is ideally placed to lessen the force of the gap. How a nurse should be to nurse well or excellently is to be someone who recognizes suffering and does something to relieve it. Suffering is the normative term and can frequently be confirmed by empirical methods (Copp, 1990). While character and virtues are important, they are so because they seem to reliably lead to good effects. The facts of human need and suffering in front of nurses daily can provide a naturalist ground for a realist account of morality that can be a part of having the virtues. At least such facts seem more plausible as an account of the nature of morality than expressivism, nihilism or non-naturalist realism. But this needs remain a stipulation in this paper. However, it is a stipulation with strong intuitive backing from experience of and reflection on nursing

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Character and virtue are important for nursing practice, and nursing practice is plausibly a moral concern. However, caution is needed in the emphasis placed on the agent’s psychology and the drift to a virtue ethics. There is something the phronimos gets right. Epistemically, the virtuous character of nurses may (but need not) lead the nurse to reliably do good things. For the most part, nursing practice needs no explicit justification as for the most part what nurses do is morally good by any theoretical lights. But when situations become complex an objective ground for nurses’ judgements and decisions may be required, and this seems to follow a consequentialist account. A consequentialist approach seems to be especially plausible for nursing as the resultant gap in the ‘dualism of practical reason’ may to some extent be lessened in force by what nurses do.

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