Most studies analyze ethical decisions as if they occur in a vacuum. Yet all decisions are made in a context that has a profound impact on both the decision maker and the decision. It’s this web of realities, human and otherwise, that constitutes the field of quantum ethics. Ethics is a discipline in which one applies certain principles so as to determine the right thing to do in a given situation. Principles are guidelines derived from philosophical perspectives (utilitarian, rights-based, duty-based, etc.). Right choices are those that conform to the ethical norms or principles, and others can know whether or not one has made a right choice (often based on their perception of human rights). Human rights are just claims to the fulfillment of fundamental, universal human needs. On the other hand, morality is the degree of congruence between what one perceives as right and one’s actual behavior; it is intensely personal, and others cannot know whether one acted morally.

Although studying ethical decision making helps determine what’s right, it doesn’t explain why people choose to do wrong, to act entirely contrary to their own principles. One could claim people are ignorant (of the consequences), clueless (don’t know the ethical import of their decisions), or evil (want to harm others). Unquestionably, people often don’t think through their decisions, and some unethical behaviors are so ingrained people simply accept them as normal. People also become incrementally habituated to certain behaviors, so even though they once thought them wrong, they no longer do.

And some people just don’t think at all: Think of how many times has one heard “Never shake a baby”—yet babies still die from shaken-baby syndrome. Others think a principle is good but doesn’t apply to them; people still drink and drive in the belief they can hold their liquor—yet they injure and kill thousands yearly.

Understanding our “dark” side

Cognition is conditioned by habit, reinforced by peer pressure, swayed by self-interest, and obscured by delusion. Even anxiety may blind one internally to the implications of decisions. Externally, the context within which a decision is made may limit one’s ability to see its ethical dimensions. For example, aspects of everyday work life—rewards, compliance systems, various pressures—contribute to ethical fading, a process that obscures the ethical dimensions of a decision. Thus, we classify something as something else—a clinical decision or a business decision—rather than an ethical decision, which increases the likelihood of unethical behavior.

Where conflict exists between professional codes and standards and institutional expectations of productivity, or between patient load and overtime, nurses may experience cognitive dissonance as their choices reflect one or the other, but not both.

Moreover, the impact of health care’s pervasive team mentality is significant: All people need to feel connected and a reciprocal need not to feel separated. These powerful needs are intensified by the techniques used to form effective teams. So team members may experience:

• action anxiety—intense anxiety created when team members diverge from group norms
• negative fantasies, in which team members imagine that contravening prevailing norms will have terrible consequences
• failure to assess the real risk of negative fantasies so that a potential risk becomes a probable outcome.
• justification of hopelessness (“I can’t do anything about it”).

Toward resolution

Laura Nash describes two kinds of problems—acute dilemmas and acute rationalizations. An acute dilemma arises when a person doesn’t know what’s right. An acute rationalization arises when a person knows what’s right but doesn’t want to do it. What’s the difference? When you start making excuses for your decisions (before or after the fact), it’s because you’re rationalizing. Yet, honestly facing the fact that you chose to do something you believe to be wrong and that you’re responsible for the hurt that follows will improve future decision making. Finally, make the implicit explicit. Communicating—not just a decision, but also its rationale—to others clearly and openly reduces unethical behavior dramatically.

Nurses, whose decisions affect other peoples’ lives, have an ethical duty to address the web of relationships, expectations—and their own egocentrism—that influences them, lest their decisions cause harm.

Leah Curtin, RN, ScD(h), FAAN
Executive Editor, Professional Outreach
American Nurse Today

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