‘“Ethics’ or “morality” in nursing’: A response to editorial by Igoumenidis and colleagues

Igoumenidis and colleagues ¹ raise a provocative question about the use of moral language in nursing ethics discourse and whether the distinction that has been commonly drawn between the terms ‘ethics’ and morality’ matters. The short answer to this question is that the distinction made does indeed matter not just because it is misleading, but as explained by the English philosopher, Richard Hare:

in a world in which the problems of conduct become every day more complex and tormenting, there is a great need for an understanding of the language in which these problems are posed and answered. For confusion about our moral language leads, not merely to theoretical muddles, but to needless practical perplexities.^2(pp1-2)

The commonly used and actively disseminated distinction between ‘ethics’ and ‘morality’ made by nursing ethics scholars is an instructive example both of the ‘theoretical muddle’ and ‘needless practical perplexity’ that Hare was warning about, and which requires attention.

Igoumenidis and colleagues ¹ are correct in highlighting that ‘formal philosophical training’ is not a prerequisite in nursing ethics and that nursing scholars writing in the field often lack foundational knowledge in the discipline of moral philosophy. This they contend may explain the conceptual misunderstandings being perpetuated in the nursing literature. It might also explain why nursing scholars and other health disciplines have come to rely on what is in essence a popularised lay (‘folk morality’) distinction in an attempt to clarify professional accountability, for example, when professional ethics might conflict with personal values. This reliance, however, has served more to obfuscate rather than clarify the issues at stake.

Nurses, like others, use terms and concepts borrowed from moral philosophy/ethics when discussing practice situations that are perceived as having a moral/ethical dimension. However, as I have argued elsewhere, ‘like others, nurses may not always use these terms correctly’.^3(p10)

Since the publication of Bioethics: A nursing perspective (first published in 1989 ⁴ and published in 2023 as an 8th revised edition ³ ), I have consistently emphasised the critical importance of understanding moral concepts and language and their correct usage. This has included providing the etymology of key terms (including ‘ethics’ and ‘morality’), giving examples of where certain terms and concepts (e.g. rights and responsibilities) have been misunderstood and used incorrectly in nursing ethics discourse, and providing working definitions of ‘ethics’ (what it is and what it is not), ‘bioethics’, and ‘nursing ethics’. In advancing discussion of these terms and concepts, nurses are also advised to be aware that many terms commonly used in nursing ethics discourse are themselves ‘ethically loaded’ and thus, paradoxically, at risk of distorting and even corrupting debates on ethical issues.^3(p12) Ironically the word ‘morality’ is itself a case in point on account of it having a decidedly Christian religious connotation ⁵ (see, for example, the influence of St Gregory the Great’s Moralia in Job ⁶ and its introduction of the word ‘moral’ into everyday vernacular). What is often framed as a ‘moral’ issue (e.g. personal values about the impermissibility of abortion based on a religious conviction) as distinct from an ‘ethical’ issue (e.g. professional ethics requiring the care of a women at a family planning facility based on codified conduct standards) would be more fruitfully addressed as a matter of conscience rather than a conflict between personal and professional values (see discussion on conscientious objection in Johnstone).^3(pp254-264)

Igoumenidis and colleagues’ invitation to reflect and respond to the questions they raise has ramifications far beyond the pages of nursing ethics texts. At the very core of their question is the credibility of the field of nursing ethics itself. In the context of growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts,^7,8 their commentary is especially important as it also raises profound and provocative questions about the credentialing and competencies of nurse ethicists and whether their work will in time enhance or undermine the credibility of the field and profession itself. In light of this, it is imperative that the nursing ethics lexicon adopts and reflects the authenticity and authority of the well-established meanings of terms and concepts foundational to the discipline of moral philosophy from which nursing ethics has borrowed, learned from, and applied extensively to inform the ethical/moral practice of nursing.