topic 4 Q2

 Select a culture other than your own and explore their death rituals. Using Ray’s Transcultural Communicative Spiritual-Ethical CARING Tool from Chapter 6 page 179, discuss how you would adapt your nursing care in this culturally dynamic situation. 

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’s essential nature and what a nurse does or ought to do in practice? Do nurses employ
reason along with virtue in the practice of nursing? How?

Biomedical Ethics
Biomedical ethics exemplifies a number of ethical principles: beneficence, nonmaleficence,
autonomy, veracity, confidentiality, justice, and fidelity Beauchamp & Childress, 2001;
Burkhardt & Nathaniel, 2013; Edge & Groves, 1994; MacKinnon & Fiala, 2014; Veatch,
1977). “Ethical principles are basic moral truths that guide deliberation and action” in
medicine and nursing and are grounded in ethical theories (see descriptions in this
section) (Burkhardt & Nathaniel, 2008, p. 53). Biomedical ethics presuppose the ethical
principle of respect for persons (see Codes of Ethics of the American Nurses Association
[2001, 2015], Canadian Nurses Association [2008], International Council of Nurses [2006].
Beneficence is to do good and requires nurses to act in ways that benefit or are good for
patients. Nurses are obligated to act beneficently—what is morally and legally demanded
by nursing’s professional role (Burkhardt & Nathaniel, 2008, 2013). Beneficence or the
good in the nursing role and practice is complex in that nurses are required to have
scientific, ethical, humanistic, and aesthetic and personal knowledge of and competency
in holism: nurse-patient relationships; body, mind, and spiritual well-being of the patient;
cultural differences; and how the context (i.e., economic, legal, technological, and political
[power issues]) of health-care organizations are integrated into or affect the well-being of
patients, family members, or significant others (American Nurses Association, Code of
Ethics for Nursing (2015),; Carper, 1978; Leininger,
1991, 1995; Ray, 1989b, 2001, 2006; Ray & Turkel, 2014, 2015). Promoting the well-being
of patients under these circumstances requires a type of supererogation or what is known
as “above and beyond the call of duty.” It also requires incorporation of virtue and caring
ethics (see theories in this section). Nurses must always be alert to medical orders and
their own behavior that can contradict beneficent acts. Nonmaleficence is a principle that
requires nurses to act in such a way that no deliberate harm, risk of harm, and harm that
relates to doing no harm in the wake of doing good. The first principle of the Hippocratic
oath of medicine is to do no harm (Burkhardt & Nathaniel, 2008, pp. 60–62). Weighing a
potential harm against a potential benefit is a constant ethical reasoning and caring
process in nursing. Autonomy means to facilitate the freedom for self-governance or self-
organization in patients with the assistance of family members or significant others. Often
there is a critique of the principle of autonomy or self-governance in cultures, such as in
Native American culture, where decisions are more communally based (Lowe & Nichols,
2014; Smith-Morris, 2007). Allowing choice, working with the patient, family, and
community to cocreate what is needed for health and well-being is a primary nursing role.
Nurses are to be advocates of the patient through knowledgeable caring, which means
that within the principle of autonomy, there should be no coercion, paternalism,
thoughtlessness, and deception. Veracity is an ethical principle that relates to telling the
truth. “Truthfulness is widely accepted as a universal human virtue….[t]ruth-telling
engenders trust” (Burkhardt & Nathaniel, 2008, p. 65). In terms of relational caring, trust is
one of the most important ways of being (Hilsenbeck, 2006; Ray, Turkel, & Marino, 2002).

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Although a relational concept, within the notion of trust there is appreciation for the
independent existence of the other and requires “letting go” or the relinquishing of control
over the other; “it includes an element of risk and a leap into the unknown, both of which
take courage” (Mayeroff, 1971, p. 27) for truth-telling. When there is a perception of
mistrust, people hold back on disclosing their secrets or information and the adage of
“seeking one’s own counsel” is the actual truth. Veracity in health care requires patience
and courage to communicate openly and seek understanding of patient and family needs.
Confidentiality is linked with privacy and refers to the right an individual has to personal
information or secrets that are disclosed to others, especially health-care professionals.
The ethical principle of confidentiality demands that one does not disclose private or
secret information about another person with whom one has been entrusted (Burkhardt &
Nathaniel, 2008, pp. 66–68; see Health Insurance Portability and Accountability Act
[HIPAA], United States, Public Health Law 104-199). Respect for persons is the foundation
of the principle of confidentiality. Justice is “the ethical principle that relates to fair,
equitable, and appropriate treatment in light of what is due or owed to persons,
recognizing that giving to some will deny receipt to others who might otherwise have
received these things” (Burkhardt & Nathaniel, 2008, p. 73). Justice issues relate to the
distribution of the greatest good to the greatest number. In health care and public health
care in particular, the principle focuses on distribution of goods, money, and services
(distributive justice). In nations that have a universal healthcare system, the principle of
justice in the distribution of health-care goods and services is more equitable than in
nations that do not; however, health is an ever-demanding and evolving concept, so equal
distribution is an ideal rather than an achieved end in itself. The important thing about
justice is fairness. How does one be fair to the other when there is an equal or greater
demand for goods and services? It requires an attitude and belief in caring, a way of
giving and often giving up for the other. In a family situation, a mother may have to attend
to one child’s needs over the other in a particular situation. In nursing, on a unit when there
is an equal demand for care and nurse caring and staffing ratios are minimal, often
choices have to be made such that the more ill patient or the patient or family member in
the greatest need will get the attention at a particular time. Resource allocation of goods,
money, and services and interpersonal resources require sacrifice, thoughtfulness,
communication, and advocacy for direct nurse-patient care, organizational management,
and health and social policy development. Fidelity is an ethical principle that relates to
faithfulness and keeping promises. In nursing, the principle of fidelity means loyalty to the
patient within the nurse-patient relationship (Burkhardt & Nathaniel, 2008). Nurses make
promises to their patients by means of the social contract of a nursing license or
certificate of competence and as they care for the patients. Nurses must do everything in
their power to be a patient advocate. With the rise of individualism in culture and perceived
lack of mutual trust between nurse and health-care organizations, institutional loyalty has
been seriously jeopardized (Ray, Turkel, & Marino, 2002; Turkel & Ray, 2004).

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Nursing Reflection
What is a principle? Why do we have ethical principles in nursing, medicine, or health
care? What are the personal and professional codes of ethics that motivate your ethical
thinking and behavior? How have you developed principled behavior in your life and
professional education or practice? Have you found a way to clarify your values and
principles to be more cognizant of biomedical principles? What principles are priorities
in nursing practice? How do you identify with the biomedical principles when you are in
a nursing situation or educational facility? Are there times when ethical principles are
jeopardized in educational settings or in nursing practice? Do patients trust nurses,
physicians, or administrators? Do nurses trust patients, physicians, or administrators?

Ethics of Care/Caring
In philosophy, the Ethics of Care emerged during the feminist movement within the latter
part of the 20th century. Feminist ethics illuminated women’s basic moral orientation to
that of caring for others—compassion and taking care of others in an interpersonal way
(Chinn, 2013; MacKinnon & Fiala, 2014; Rachels, 2003). Gilligan (1982), one of the first
women and leading scholars of her time, engaged in a critique to correct the
misperceptions in psychology by illuminating the motives, the growth, and development of
morality of women and women’s moral commitments. The ethical principles that emerge
from most of these feminist theories of care show the dynamics of relationships and the
concept of responsibility to the other—the good is equated with caring for others. “Care
becomes the self-chosen principle of a judgment that remains psychological in its concern
for relationships and response but becomes universal in its condemnation of exploitation
and hurt” (Gilligan, 1982, p. 74). Even though the focus of modern feminine psychology
and ethics is oriented to a new approach to feminine moral development, many ideas are
based upon theological and human virtues of classical and medieval periods. What is new
is the focus of attention on relationship, the call, and response of one person to the other,
and care as central to moral development in women.

This orientation illustrates how important the meaning of care and caring was to the
survival of human beings, as has been identified in anthropology (Leininger, 1978, 1991,
1995; Tarlow, 2000). The orientation to care and caring illuminates the relational idea of
respect for self and other human beings. The character traits of caring capture the
meaning of a truly good human being, one who cares and is responsible for others. At the
same time, a caring human being is one who is conscious of the potential for selfishness
in the individual self but lives in accordance with a moral code that enhances a sense of
belonging to others, the world, and the universe at-large (Capra, Steindl-Rast with Matus,

The ethics of care and caring in nursing became prominent with the evolution of the
concept of caring in nursing and also, at the same time, the ethics of care theme advanced
in psychology. A guiding moral framework of ethical caring (enhancement and protection
of human dignity, alleviation of suffering, and the nursing event/situation) in nursing was
advanced by many theorists of caring (Davidson, Ray, & Turkel, 2011; Eriksson, 1997,
2006; Leininger, 1990; Ray, 1994a, 1994b, 1997, 1998, 2007, 2010a, 2010b, 2010c; Roach,
2002; Watson, 1988, 2005, 2008). Although complex and even paradoxical, evaluation and
research have shown that in nursing situations, nurses integrate both the ethics of
principle/duty and reason and the ethics of caring, healing, and responsibility (Cooper,

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1991; Hilsenbeck, 2006; Ray, 1987, 1998, 2007; Roach, 2002). Within this synthesis, there
usually is creative moral tension that facilitates insight into and understanding of moral
confusion and moral chaos, and the agonizing vulnerability in relation to the complexity of
ethical decision making in the nursing situation (Chase, 2004; Gadow, 1989). Nursing
continues to contribute to the understanding of caring as a moral enterprise—a value,
virtue, intentional act, reason, and practical wisdom—a call and response and
responsibility to self, others, the environment, and the universe.

Transcultural Ethics
Transcultural ethics is very complex and dynamic. Each individual is a collage and
integration of diverse values, beliefs, attitudes, and behaviors that make up human
experience. Culture relates to patterns of learned behaviors and values that are interpreted
and shared among members of a designated group and usually transmitted to others of
their group through time (Leininger, 1978, 1990, 1991). Ethics is grounded in
consciousness and conscience, which underscores beliefs about why we exist. Ethics is
humanistic and principle-based and reveals a broader religious or spiritual purpose of
reasons why we exist and how we should relate to and act with each other. Ethics is
associated with respect for persons and moral action in the lifeworld and in living with
others (American Nurses Association Code of Ethics with Interpretive Statements, 2001,
2015, The immediate purpose of transcultural
ethics is to “hear the other” and “learn from the other” with mutual respect. This validates
the idea that all people are cultural beings and have diverse values, beliefs, and attitudes.
As cultural beings relate, transcultural ethics offers a framework within which to interact.
The conscience in which this ethics illuminates strives to mitigate disrespect or elements
of misconduct and to propagate the good, purpose, truth, and beauty within the
interactions of all people and in nursing, nurses and patients, families or community

Nursing Reflection
What does an ethic of care and caring mean to you? How do you practice an ethic of
care and caring with patients? What do healing and responsibility for the other mean to
you? Is caring a universal principle and a culturally relative way of being? Do you find it
hard to practice an ethic of care/caring in nursing today? What creative tension have
you experienced between a set of principles, such as beneficence, autonomy, justice,
and compassion or mercy? What principles and virtues do you find difficult? Are you
ever morally confused about what to do in nursing situations? Have you experienced
moral conflict, blurring, or moral blindness (Gadow, 1988, 1989; Ray, 1998; Turkel & Ray,
2009) when it comes to a difficult ethical situation in nursing or health care? Have you
seen immoral behavior in nursing or medical practice, outright wrong actions? How
have you dealt with observable or your own silent moral problems? Are there gray areas
in nursing ethics either in the classroom or in nursing practice situations of potential
cheating or deceiving the patient or the organization, truth telling, and promise keeping?

In today’s challenging global culture, transcultural ethics seeks to understand
differences in people in interaction with others. Transcultural ethics validates the idea of
increasing and learning compassion and reaching out to alleviate suffering—to help

1847212 – F. A. Davis Company ©

human beings by meeting needs and trying to secure human rights (individual or
communal), and do what is just for others (Dalai Lama 1999; Hirsch, 1976; Leining

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