Nursing as a profession tends to hold a liberal view of politics and social justice. A strong belief in the autonomy of the professional as well as the patient is emphasized in the professional conversation. Most nurse leaders would support equality of opportunity in education, health care, and in competition for other scarce resources.
Nurses are both persuasive and compassionate—working tirelessly for the benefit of the public. This political role of professional nurses, along with the current climate in Washington D.C., prompted me to write about an overriding issue that seems to be derailing the political process in this country. I am hoping that insights derived from my own and others’ research on moral certainty and in moral uncertainty might provide guidance for nurses trying to navigate the political process.
The George W. Bush administration coined the term “moral clarity” to support its political belief that there is always a morally optimal solution to the political crises of the day. Moral clarity became synonymous with a morally certain view of life’s distressing and ambiguous realities. It became the philosophical support for the invasion of Iraq, the political and philosophical underpinning for the Patriot Act, and support for the beliefs that led to the moratorium on stem cell research.
There is a tension between moral clarity and moral ambiguity and uncertainty as applied to our current political process. Most philosophers suggest delaying judgment, seeking more information, and being aware that one’s own judgment can be flawed when making decisions. In the current political climate, however, many of our legislators appear to believe with certainty that their own judgments and knowledge are unassailable. Until we recognize, as a culture, the moral uncertainties and ambiguities facing us in the future, learn to live with them, and make our decisions based on them, we will not be able to resolve some of our most pressing concerns as a nation and as nurses.
There are a variety of views about what certainty and conviction are and what causes them. Dr. Robert Burton, a neurologist and author of the book On Being Certain: Believing You Are Right Even When You’re Not, argues that moral certainty, or what he calls “the feeling of knowing,” is an emotional state not unlike fear, anger, or anxiety, which can occur in the absence of knowledge. This “feeling of knowing” is an internal mental state or sensation, not a deliberate conclusion or conscious choice. Because it occurs suddenly and without conscious thought it may lead to taking a reasonable position or it may not.
Judy Johnson, who has studied moral certainty, or what she calls “dogmatism,” for more than 20 years, believes that there are “four psychological pillars of dogmatism”—the need to know, the need to decrease anxiety, the need for social connection, and the need for personal dignity. She goes on to describe five cognitive characteristics of dogmatism—intolerance of ambiguity, defensive cognitive closure, rigid certainty, compartmentalization, and lack of personal insight. Her research suggests that the behavior of such individuals demonstrates a preoccupation with power and status, glorification of their group and vilification of others, authoritarian aggression, strict adherence to conventional conduct, and an arrogant, dismissive communication style.
Dogmatism has deep psychological and functional underpinnings that are very destructive to the political process. The issue, according to Johnson is “closed minds versus open minds” and dogmatism versus reason. She insists that it is not about one political system or another, ineffective or effective leadership, nor about change or stasis, but about emotional belief systems. She believes failure to consider moral certainty (dogmatism) leaves the political process vulnerable to manipulation by those who knowingly intensify our fears such that we close our minds to reasonable alternatives.
The challenge is to open our minds. As Voltaire commented, “Doubt is not a pleasant condition, but certainty is absurd.” Doubt or moral uncertainty requires humility and prepares us to confront all forms of ideological extremism. Those who espouse moral certainty exploit our complacency and fear in turn constricting our political and individual thought process to the point of becoming oblivious to dogmatic agendas of totalitarianism, religious fundamentalism, terrorism and all forms of fanaticism. The primary destructive consequence of moral certainty is that its inflexibility closes the mind to contradictory evidence, which might lead to more socially and politically beneficial outcomes. The common good is stymied by a constituency of closed minds.
Sherman contradicts both Burton and Johnson and believes that moral certainty is primarily a difference in value orientation. He cites studies performed by Jonathan Haidt that suggest that liberals and conservatives emphasize different moral values and tend to sort into two categories —one with values concerned with harm/care such as empathy, sympathy, and fairness/reciprocity (liberals) and another which emphasizes group loyalty, authority/respect and purity/sanctity (conservatives). He sees both orientations as merely differences in values.
My own research indicates that the morally certain person takes action without consultation with others, has an absolute conviction about the “rightness” of his or her action, and does not feel remorse or the need to “second guess” himself or herself. The morally certain person takes action without deep contemplation or the need to question the action taken, frequently disregarding the social consequences of his or her own actions. In almost all cases I have examined, the more experience a nurse has with an issue the more likely he or she is to have strong convictions about the issue, suggesting that moral conviction and certainty in my studies were learned behaviors, unlike Burton’s belief that “the feeling of knowing” may be genetically transmitted.
In contrast, there are positive aspects of both moderate conviction and moral uncertainty/ambiguity. Moderate conviction allows one to “stand up or “speak up” but still recognize the rights of others. Nurses who have moderate conviction are able to resolve difficult issues, maintain a dialogue with others, and stand up or speak up for what they believe.
Moral uncertainty, which is often characterized as uncomfortable—the most prominent word typically expressed by nurses in my research was “torn”—has a beneficial effect on ethical and political decision-making. It leads to a search for knowledge and information. It sparks dialogue among peers and above all it promotes consensus building. Invariably, morally uncertain nurses strive for agreement among the parties to the solution.
Economists, decision theorists, cognitive psychologists, and those interested in risk management have examined decision-making under conditions of uncertainty. According to decision theory researchers Beyth-Morom, Dekel, Gombo and Shaked, our feelings of uncertainty are not constant. One feels more or less uncertain based on additional information. Moreover, they and I have found that uncertainty does not keep us from taking action. When faced with important decisions we act, but with careful consideration of the options and still in doubt. In fact, Lockhart believes that sometimes individuals can enter into collective arrangements that prevent moral dilemmas that would otherwise arise. One important way in which individuals, in cooperation with others, can avoid moral dilemmas is to develop solutions in which all of the options are morally defensible.
Dennis Lindley believes that uncertainty is many times suppressed because most people prefer certainty, but that uncertainty is ubiquitous and in most cases it is better to acknowledge it rather than suppress it. In my own view, using moral uncertainty to further the debate and resolution of issues is not only rational, but also very practical. Making decisions while searching for more information, having a dialogue with colleagues, and trying to come to consensus amplifies the positive aspects of not only the decision outcome, but of the process itself.
The beginning of wisdom is coming to an understanding of the complexity of moral judgments. This means acknowledging the tension between equally fundamental but contradictory moral beliefs, along with the multiplicity of possible interventions. Instead of pursuing a search for moral certainty, living with the ambiguities of the ethical life is not only suggested, but recommended. Although some statements of fact may be tentative, one can have sufficient knowledge to take moral action, subject to revision of one’s point of view, with the accumulation of more evidence.
In our political interactions we should endeavor to respect each other’s moral judgments, try to see the issue from the other person’s point of view, discuss liberally, and make some concessions for the sake of agreement. The art of negotiation and compromise is based on persuasion, trust, and reciprocal concessions rather than on force, threat, or intimidation.
While moral clarity or certainty is frequently the comfortable position to take, moderate moral conviction allows for intellectual appraisal of the pros and cons of an issue and, combined with an original position of moral uncertainty in a morally ambiguous situation, often leads to an optimal perspective. As uncomfortable as moral ambiguity and uncertainty are, they hold the promise of deep thought about the many consequences of our political actions for the human community and they promote unparalleled seeking of knowledge, dialogue, and consensus.
Moral uncertainty, as related to politics, holds many implications for nurses as individuals and nursing as a profession. As individuals, nurses need to appreciate the profound benefits of consensus-seeking in politics. Moral uncertainty is one of the primary psychological drivers of seeking consensus through information gathering, negotiation, open conversation, and sharing of values among members of, not only the profession, but the public and even traditional political parties.
Consensus is made possible by moral uncertainty and its consequences, making the political process develop and converge upon optimal decisions and solutions. Consensus not only improves the political process, but also makes the manifest legislative agenda more easily acceptable to a wider variety of constituents from a plethora of political viewpoints and backgrounds.
The primary goal of using moral uncertainty to promote consensus is the end result of bringing nurses, the public, politicians, and society together. A profession and a society that promotes agreement among their members are able to develop and grow in optimal ways while protecting their most vulnerable and providing for the common good. The common good can only be obtained through consensus, and moral uncertainty directly supports this necessary function of the political process. Moral uncertainty leads to consensus, which in turn results in healthy, progressive, and efficacious outcomes for nurses, nursing, and society.
Mary Ellen Wurzbach is John McNaughton Rosebush Professor Emerita, College of Nursing, at the University of Wisconsin in Oshkosh.
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Selected References
Beyth-Marom R, Dekel S, Gombo R, et al. An Elementary Approach to Thinking Under Uncertainty. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers; 1985.
Burton RA. On Being Certain: Believing You Are Right Even When You’re Not. New York, NY: St. Martin’s Press; 2008.
Haidt J. The moral emotions. In: Davidson RJ, Sherer K, Goldschmidt HH, eds. Handbook of Affective Sciences. New York, NY: Oxford University Press; 2003.
Johnson J. What’s So Wrong with Being Absolutely Right: The Dangerous Nature of Dogmatic Belief. Amherst, NY: Prometheus Books; 2009.
Lindley DV. Understanding Uncertainty. Hoboken, NJ: John Wiley & Sons Publishers; 2006.
Lockhart T. Moral Uncertainty and Its Consequences. New York, NY: Oxford University Press; 2000.
Shermer M. The Believing Brain: From Ghosts and Gods to Politics and Conspiracies—How We Construct Beliefs and Reinforce Them as Truths. New York, NY: Time Books, Henry Holt and Company; 2011.
Voltaire. http://www.brainyquote.com/quotes/quotes/v/voltaire132729.html (accessed August 19, 2013).
Wurzbach ME. Nursing ethics and Hagar the Horrible. Reflections on Nursing Leadership. 2005;31(3):18,19,28.
Wurzbach ME. Moral conviction, moral regret, and moral comfort: theoretical perspectives. In: Pinch WJE, Haddad AM, eds. Nursing and Health Care Ethics: A Legacy and a Vision. Silver Spring, MD: Nursebooks.org; 2008.
