Ethical dimensions of community health: increasing awareness.

Abstract

Nursing, like the changing society of which it is a part, is beginning to focus on ethical and moral dimensions. Nursing interventions traditionally based primarily on scientific and theoretical knowledge, previous clinical experience, or personal capabilities are now being considered within the realm of moral decision-making. In any age where organs are transplanted, pregnancies terminated by elective abortions, and lives maintained by artificial means, the nurse is constantly faced with situations arousing moral discourse at each step in the nursing process. The nursing process is one of continuous decision-making in which value commitments are inherent. Moral judgments made by nurses influence patient decisions and impact on their relationships with other health professionals within the work setting. For example, community nurses providing home health are placed in the conflicting situation of trying to document a need for skilled care for a Medicare patient whose needs are primarily of a psychological nature. The nurse also encounters less obvious conflicts that demand moral decisions. Yet, the majority of nurses have not received educational preparation to assist them in making decisions in situations that involve moral judgments (Crisham, 1981). The nursing profession has begun to recognize the need to facilitate the moral development of its practitioners. Kohlberg's (197 1) cognitive theory of moral development has provided the framework for this advancement. A prevailing assumption of Kohlberg's theory is that persons functioning at higher levels of moral development will make decisions that are supportive of the dignity, values, and rights of all concerned. This theory describes three levels of moral development ranging from a low preconventional level with an obedience/punishment orientation to a more principled, altruistic level. A key concept necessary for one to advance to the principled level of moral decision-making is role-taking. Role-taking occurs when an individual experiences