Ethos: The heart of ethics and health

Abstract

Background:

Ethics in nursing care are traditionally discussed in terms of moral norms or principles. When taking an ontological approach to ethics, ethics is about ethos. Ethos involves both an internal and an external side of ethics. Considering ethics and health from an ontological perspective can provide a different understanding of ethics and health in caring and nursing.

Aim and research question:

The aim of this study is to deepen the ontological understanding of ethics and health in caring and nursing. The research question is as follows: What is the ontology of health and ethics in caring and nursing?

Research design:

The study follows a hermeneutical design inspired by Gadamer. Participants and research context: essays about ethics and health were gathered from PhD students in nursing and caring sciences.

Ethical considerations:

The research follows Responsible conduct of research guidelines provided by the Finnish Advisory Board on Research Integrity.

Findings:

An ethos with the values of freedom and responsibility seem to ontologically be important for ethics and health. These values allow a movement between the internal and the external sides of ethics that is important for health.

Discussion:

The ethos of freedom and responsibility that is essential for ethics and health can provide the current ethical debate a new starting point that previous research asks for.

Conclusion:

Ontologically, an ethos of freedom and responsibility is essential for ethics and health in nursing and caring.

Keywords

Ethics of care/care ethics ethos health hermeneutics ontology theory/philosophical perspectives

Introduction

In ancient Greece, a human being was seen as a natural part of nature and the surrounding world; consequently, this also meant that human health was seen in relation to this entity. In the 15th century, there was a scientific split between the Aristotelian and the Galilean worldview in Western society. The Aristotelian worldview, where a human being was seen as a natural part of a greater whole, was gradually substituted for a Galilean worldview in which humans were studied in isolation from the surrounding word. For health, this meant that it became a focus on symptoms and treatments of specific illnesses; meanwhile, the perception of health as part of a greater whole was forgotten.¹ In time, health as an entity became forgotten and the understanding of health became more difficult to grasp, then health became something enigmatic and mystic.^2
–4 The same faith happened to ethics, ethics was separated from the entity and ethics was seen as something external—something casual. That is ethics was seen best safeguarded through following external values as laws, directions, norms, and rules, and the internal side of ethics, based on human personal values, became overshadowed. This split is still evident in caring and nursing where the external approach to ethics has dominated for a long time. But this approach has been shown to be difficult to apply to the complex nursing practice and recently, different approaches based on internal ethics have entered the field as an counterforce to the external approach to ethics.^5
–7 However, still something vital seems to be missing in ethics developed for caring and nursing,^8
–10 and there is still a need to reconsider ethics. Looking at ethics and health in caring and nursing ontologically may offer a new approach to ethics and health. Reconsidering ethics ontologically ethics is about ethos, that is, personal human values that is a synthesis between personal values and the culture and history a human being is part of.¹¹ This alternative approach can perhaps offer the ethical debate in caring and nursing research a new starting point.

Aim

The aim of this study is to deepen the ontological understanding of ethics and health. The research question is as follows: What is the ontology of ethics and health?

Concepts of health, ethics, and ethos in caring science

In caring science, Eriksson, among others, in her early work rediscovered health as an entity. In Eriksson’s¹² case, this was accomplished through a concept analysis of the concept “health.” This discovery became an important part in formulating her theory of caritative caring, in which she reestablished a holistic view of health, following this, the ontological health model was formulated. In the ontological health model, health is seen as an entity, as a movement on the levels of doing, being, and becoming in the presence of suffering.^13
–15 Parallel to the research on health, Eriksson¹⁶ also initiated a research program in ethics. In this program, the focus also was ontological in order to grasp the deeper dimensions of ethics. The caritative caring theory is based on an Aristotelian worldview; therefore, ethics is about what a human being is and what she shall do.¹⁰ So, in the beginning of this research, the focus was on morals and ethics. But through the ontological focus, it was discovered that caring and nursing ethics are more about what happens in relationships among human beings. Then, the focus in caritative ethics shifted from morals to ethos (values). As a consequence of this shift, dignity and virtues became the interesting research areas in the caritative caring theory. Because ethos is based on a communion,¹¹ dignity, with regard to what happens or, worse, what does not happen that should be happening in the relationship among human beings became a central point of focus.¹⁷ Dignity is respecting the other’s otherness and uniqueness in a caring relationship. Research within the caritative caring theory further shows that the experience of dignity affects every person in a caring relationship. Health prospers for every person in the caring relationship if the relationship carries a stance of dignity. However, if the relationship includes violations of human dignity, then also every person in the caring relationship suffer.^{17

–28} Due to the ontological approach, virtues became a central element in the ethics developed within the caritative caring theory. Virtue is a description of good character traits. Virtue answers the question, Who should I be? The desired answer should be “a good human being.”¹⁷ Hence, what is considered as virtue is strongly influenced by ethos. In the caritative caring theory, Näsman’s²⁹ research suggests that ontologically, virtues have importance in the movement between ethics and health in caring and nursing.^28,30 However, if ethics ontologically is about ethos, values, ethics, and health, it consequently must comprise more than virtues. Ethos is a human value base, which is formed internally through a person’s own values. When a human being connects to his or her ethos, a sense of at-homeness occurs. The sense of at-homeness gives a human being courage, joy, warmth, and an inner force. Ethos is made concrete through human actions.³¹ In caritative caring theory, the sense of at-homeness is a stepping stone to arête, that is the essence of virtue where the willingness to serve, take responsibility for the realization of what is good, and to do something wholeheartedly for the patient become concrete.^17,29,32 In a caritative caring culture, it is also desirable that the culture would carry an ethos of human love and charity, that is, caritas. The values of love, mercy, and dignity is integrated among nurses through a continuous movement between the inner side (ethos) and the outer side (arête).^{11,24,31,33,34}

Previous research on ethics and health in caring and nursing

A literature search using the keywords “ethics,” “ethos,” “health,” “caring,” and “nursing” in different combinations was done in relevant databases: EBSCO, CINAHL, ebrary, MEDLINE, PubMed, and Google Scholar. The large amount of hits shows that this subject has significant focus in caring and nursing research, and there still seems to be a lot of unanswered questions and confusion regarding ethics and health. Ethics and health also have a multidisciplinary interest in research. Ethics, in its core, is about questions of what is good and is, therefore, as universal as health. In the complex nursing reality, however, deciding what is good in the specific situation is a demanding task, which can be influenced by many factors.³⁵ However, in nursing research, an external focus still appears to dominate ethics, in which morals and norms guide ethical thinking. The external approach, however, does not seem to be up to the task of alleviating suffering in every situation. Even suffering is reported, both from nurses as distress in ethical decision-making and from patients who due to the autonomy principle, feel left alone with an ethical decision that they cannot grasp the full consequences off.^36
–38 Hence, in caring and nursing ethics, something vital still appears to be missing.^8
–10 Previous research also shows that ethics is both about internal and external values,^36,39,40 but in caring and nursing, there is still a focus on ethics as external values. Many ethical approaches are, therefore, still based on causality emerging from existing ethical theories, as utilitarianism and Kantianism.⁴¹ However, research shows that these theories do not face up to all the challenges that complex caring and nursing reality bring.⁴² External ethics can be a guidance, but in the end, an informed moral judgment in the specific situation is always needed.⁴³ Distress is reported when there is a conflict between external and internal values in caring and nursing. Nurses report that they feel distress when they are obligated to choose between what they are ought to do, according to the ethical guidelines, and what they believe is the right thing to do for the individual patient.³⁶ The nurses have to choose between the ethics of justice (principles, legislation, etc.) and the ethics of care (the understanding they have from experience). In a practice dominated by external ethics, the questions “what” and “why” (i.e. “What are we doing exactly, and why is it good”) become overshadowed by questions of “how we should do this”^43,44 and ethics become a proceduralism.^45
–47 An external ethic is even reported to hinder nurses from achieving what they believe is their professional duty in a specific situation and they feel that they are not doing an optimal work.⁴⁸ Hence, there still seem to exist a lot of unanswered questions regarding ethics and health in caring and nursing.

Materials

During a PhD course in ethics, 2011, at a university in Finland, PhD students from the Nordic countries came together. During this course, the students were asked if they were interested participating in a research in the ethics research program.¹⁶ Those who participated had a personal interest in ethics as they attended the course and were therefore interested in participating. They were asked to write essays after the course, answering the question What is the connection between ethics and health? When writing the essays, they were asked to give themselves plenty of time, a few days, to formulate their thoughts. They were also asked to focus on an inner ontological ethic in their essays. A total of 13 essays, which consisted of 17 pages of text in total were gathered. Because the participants were PhD students in nursing and caring science, they had a rigorous pre-understanding of caring and nursing from both a practical and a theoretical perspective. Previous to writing the essays, participants were also asked to read eight selected articles about ethics and health. The articles were selected by the researchers as a result of a large systematic literature search with focus on the ontological relation between ethics and health.

Message from the articles

An overview of the essays and articles read by the students was done with help from N-Vivo 10 (Stanford University). This overview helped the researchers to grasp the general message in the articles. The general message in the articles was that ethics in caring and nursing still strongly reflect the scientific split. There is a focus on developing ethical principles, norms, rules, and regulations to govern caring and nursing. The articles discussed that principles, norms, and rules, however, were not up to the task of supporting an ethical climate in the complex caring reality. Moreover, norms and rules are often perceived as being distant and abstract in practice.^5
–7 The articles enlightened that there is a general perception in caring and nursing that something vital is still missing with regard to ethics.^5,6,36 Recently, there has been a focus on internal values, but the articles also enlightened the weaknesses of such an approach. For example, virtue ethics are criticized as being an ethical base in caring and nursing.⁶ So is an ethic based on human relationship where the assumption is that the vulnerable human being triggers a caring response. There is no guarantee that a vulnerable human being awakes a caring response, and there is a risk of power relations that induce suffering in this approach.³⁸ The articles also show that in caring and nursing today, there is a battle between the two ethical perspectives. This typically leads to confusion, and nurses suffer from moral distress when their values are in conflict with external ethics; in some cases, nurses may even feel restricted to do what they perceive as good work.⁴⁹ Because there is no consensus in caring and nursing ethics, nurses may also develop their own homemade ethical strategies to cope with the ethical challenges in caring and nursing.⁵ This may be a risky path to take.

Method

The essays were interpreted hermeneutically by a method inspired by Gadamer.⁵⁰ On the first level of interpretation, a naïve reading was done, and a naïve understanding was formulated. Second, a new deeper interpretation of the essays was formulated, and the relationship between the parts and the whole text was regarded. Third, an in-depth understanding of the essays was formulated when the interpretations were reflected against the theory of caritative caring in order to gain a deeper understanding of the ontology between ethos and health. The interpretations were always checked against the whole text mass and the naïve understanding so that no disagreements in the material could be detected.^50,51

Ethical considerations

The research follows ethical principles according to the recommendations by the Finnish Advisory Board on Research Integrity.⁵⁹ For the purpose of this study, this means that the research is expected to be reliable, and that confidentiality and anonymity of the participants are guaranteed. Literal quotations have been used, but no information about the participants’ social situation or anything else that might have produced intrusion into their privacy has been described.

Findings

The hermeneutic interpretation of the essays went from a naïve understanding to a deeper level of understanding to an in-depth understanding in order to gain novel understanding of the ontology of ethics and health.

Naïve understanding

The naïve understanding is that both ethics and health have internal and external dimensions. Health, as something external, is about symptoms and diagnoses. Health, as something internal, is about health as a subjective experience. Ethics, as an external ethic, are about norms and morals, and ethics, as an internal ethic, are guided by personal values formed gradually over time. In caring and nursing, the view on health has gradually changed, and health is nowadays seen as something more than absence of disease, as an entity:

As I see it on the ontological level relates to the whole. Health is our spiritual dimension in this live our values. (Essay 12)

However, ethics are still affected by the scientific split and are still regarded as something either internal or external. In caring and nursing, the external dimensions of ethics still seem to have a dominating position:

It is often external ethics norms and rules that govern public health practice. (Essay 7)

But external ethics alone do not seem to be up to the task in caring and nursing:

The problem of ethical issues are born when ethics are transformed from the universal to the patient’s situation: what is best for this patient at this time. (Essay 1)

Ethics is typically shaped in the moment, through both internal and external values:

Ethics is not just about good deeds but also about the spirit in which the good deed is done. I can teach good deed and a deed may look like a good deed, but it is only the recipients of the good deed that can see it in the spirit it was made. (Essay 9)

When looking at ethics ontologically, as ethos, a broader understanding can be reached. When looking at ethics as ethos, there is evidence that a movement between the internal and external sides of ethics is important for health:

Health is deeply rooted in every human being and has an ethical dimension. (Essay 9)

It can be difficult to live a happy and harmonious life of health if it is not ethically sound. Health presupposes ethics. (Essay 4)

Good ethics are the prerequisite for a movement toward health as a sense the wholeness. (Essay 5)

My health and my internal ethics and patient’s health and internal ethics is a caring relationship that are interrelated and should not be separated from each other as little as health and ethics can be separated from each other. (Essay 9)

If ethics in caring and nursing are seen as something either external or internal, the movement between ethics and health is stagnated, and there might be suffering. Therefore, it is important to take the internal and the external dimensions of ethics and ethos into consideration in order to gain new understanding of the movement between ethics and health.

Deeper understanding

Two values, freedom and responsibility, emerge as essential for ethics and health in caring and nursing. Through freedom and responsibility, a continuous movement between ethics’ internal and external sides can be established, and human health and dignity can be safeguarded. This is made concrete in a caring relationship. When a nurse in a caring relationship has freedom to invite the patient and take responsibility for the patient’s health, a connection between ethos and health is established:

Daring to see the other and invite the others in community is perhaps the caritative ethics deepest base. (Essay 10)

In the caring relationship, ethos serves as a compass that guides health in the uniqueness of every situation:

The internal ethics helps the caregiver to invite the patient, to take responsibility to esteem the holiness and dignity. (Essay 4)

In the inner room is the voice of conscience, an inner compass. (Essay 7)

Every patient has different values and requirements for their health. The health and its value can vary from person to person. When the nurse is face-to-face with the patient, she must be very sensitive and intuitive when she “reads the patient” and thinks about which ethical approach suits the patient. How can I appreciate his/her views on health and how can I care for the patient in the best possible way? (Essay 11)

The internal and the external ethics is essentially different, at the end of the day the internal ethics will be the ruling. (Essay 3)

And human dignity is safeguarded:

In the outer room, responsibility is related to equality and rights. In the inner room, it can be seen as a link between dignity and responsibility. (Essay 7)

However, if there is only a focus on external ethics, human dignity can be threatened, and the movement between ethos and health stagnates:

Another ethical dilemma that may arise in practice is when personal values are in conflict with the organization’s values. (Essay 1)

In such a culture, a culture of shamelessness might be developed where duty goes as far as following the principles and norms, but no further because there is no freedom and no responsibility:

Health and ethics are linked to the experience of responsibility, guilt and shame. (Essay 9)

In-depth understanding

In caring and nursing, health seems to have evolved and has gained status as multidimensional, but ethics still seem to be stuck in the scientific split and are seen as either something external or something internal. Looking at ethics and health ontologically shows that ethics are actually about ethos. Ethos is values that have been formed through culture and history, a fusion of both internal and external ethics. Ethos is also referred to our habits, for example, the way we do things.¹¹ Habits can be good and lead to good health, but habits can also be bad and cause suffering. To avoid the manifestation of bad habits and to have existing bad habits questioned in caring and nursing, it is critical that the ethos in caring and nursing have a stance of freedom and responsibility. Freedom enlightens bad habits and responsibility changes and breaks bad habits. The importance of freedom and responsibility in caritative ethics has been previously enlightened.²² To cultivate and create good habits and break bad habits, freedom for reflection, discussion, and training is important. This is something that can be related to the Gadamerian concept of Bildung, that he describes as self-formation, education, or cultivation^4,50

The internal ethics have keeper acquired through training, such as through experience, discussions and role models. (Essay 4)

Movement between the inner and outer ethics does not take place only in relationship to yourself, but also in relation to others. (Essay 13)

For the participants in this study, this self-formation, Bildung, in ethics and health happened when the participants took part of the articles and attended lectures about ethics and health:

I think my views on health and ethics grew a lot during these three days. (Essay 13)

The participants enlightened the importance of this Bildung:

The nurse must have a personal, aesthetic, empirical and ethical knowledge when she shows the patient the right path to health. (Essay 11)

And the responsibility nurses have to gain Bildung:

It is important and that the debate about ethics is open and current. There must be a constant questioning the ethical norms behind various decisions and actions in practice. (Essay 5)

One should as a nurse bear the responsibility to keep running a discussion on ethics in practice. (Essay 1)

Ethos and ethics are united in Bildung when a person reflects upon the basic human values and carries them into effect.¹⁰ Hence, Bildung has been shown to be important to both nursing education^6,33 and nursing leadership.³⁴ Furthermore, as ethos refers etymologically to home and a sense of at-homeness,^11,31 finding a place in life where a human being is comfortable with his or her values is important. In the caritative caring theory, the sense of at-homeness is concretized as arête. Arête is a spirit of willingness to serve, take responsibility for the realization of what is good, and to do something wholeheartedly for others.^{12,13,17,29,31,32} Through arête, the true, the beautiful, and the good can be realized and caring can become the core of nursing.

Discussion

The results show that an ethos of freedom and responsibility is central for ethics and health in caring and nursing. Freedom and responsibility²² are concepts previous studied in caring science as well as the concept ethos.^11,31 The weakness of the results of this study may be that these specific concepts emerge strongly in the literature, and also in the literature the participants studied during the course. Consequently, they may have influenced the answers. However, the participants are academics with a rigorous experience of caring and nursing sciences from different disciplines which may indicate that they are not easily led as they process a critical and analytical capacity. The practical and theoretical experience of the participants can also be considered as strength in the study. The results show that the ethical approaches developed in caring and nursing still seem to be stuck in a dualistic perspective.¹⁰ The ontological perspective may provide new evidence⁵² to expand the dualistic perspective. By dualistic perspective, we mean that in ethics, there is a focus on either ethics as internal or external. The ontological understanding may broaden the dualistic perspective by focusing on the movement between ethos and health.^{5
–7,35,36,39,40,49} The dualistic perspective reflects that ethics in caring and nursing still reflect the scientific split^1,40 where ethics is either something casual, guided by external moral rules⁴¹ or something subjective guided by internal values.^{6,28,36,39,40} In caring and nursing, there even seem to be a conflict between the two approaches.^3,12,14,15 When considering ethics and health ontologically as ethos, the movement between external and internal ethics becomes important, and one cannot have one without the other.¹¹ The scientific split in caring and nursing can affect the movement between ethos and health negatively. In western-style healthcare systems, the focus on external ethics⁵³ may even restrict freedom and responsibility and, consequently, the movement between the external and internal sides of ethics in caring and nursing. Western-style healthcare systems are even said to restrict nurses caring and loving possibilities⁵³ although love is a cornerstone in many well-established caring and nursing theories.^{14,22,23,54,55} If there is a focus on merely external ethics, ethics become a proceduralism, or an ethics of justice,^42

–46 and values such as freedom and responsibility are overshadowed. The risk in such a culture is that a culture of shamelessness might be developed, where Arendt⁵⁶ says the banality of evil dominates. People stop thinking and are just doing—as robots. They do what they are supposed to do, as bureaucrats, according to external rules—without reflection of how the actions affect others. In a culture of shamelessness, the bureaucratic thinking demands no guilt or shame if suffering is induced. In caring and nursing, both shame and guilt are needed to preserve human dignity and to avoid the development of a culture of shamelessness. Shame is even a more powerful ethical motivator than guilt because guilt is experienced toward others, but shame is toward yourself.^57,58 The ethical mantra developed by Eriksson,³² “I was there, I saw, I witnessed and became responsible,” is therefore important in avoiding a culture of shamelessness. The ethical mantra justifies freedom to see, to witness, and to be responsible; thus, in this guilt and shame becomes an important motivator. When an ethos of freedom and responsibility becomes the heart of ethics and health in caring and nursing the ethical mantra becomes alive and safeguards human dignity.

Conclusion

Ontologically, an ethos of freedom and responsibility unites ethics and health in nursing and caring. The ontological approach gives a broader perspective and a new understanding of ethics and health in caring and nursing and how ethos is realized by means of arête. Further research creating new ontological evidence of the connection between ethos and health is, however, needed to broaden the perspective.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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