María Antonieta Castañeda-Hernández,1 José Enrique Gómez-Álvarez2
1División de Innovación Educativa, Coordinación de Educación en Salud, Instituto Mexicano del Seguro Social; 2Facultad de Filosofía, Universidad Panamericana. Distrito Federal, México
Correspondence: María Antonieta Castañeda Hernández
Keywords: Nursing; Health vulnerability; Morals; Cultural competency
The moral aspects of human behavior have always been of interest and controversy to individuals and institutions. Inquiring about the nature of moral values and the role of education in the development of morality has been a central concern for philosophers, religious leaders, and educators. The study of morality frames reasoning and moral behavior, which constitute two relevant personal dimensions to consider.1
Lawrence Kohlberg uses a cognitive-evolutionary approach to ground one of the most comprehensive theories of human development in moral dimensions; this theory applies the scheme of stages of development that Piaget developed to study thought. A stage is a conscious and distinctive way to apprehend reality, with properties that involve qualitatively different ways of thinking and solving the same problems; these forms can be ordered in an invariable sequence, in which each of these ways of thinking forms a structured whole; i.e., at each stage the individual's beliefs are organized around that way of thinking; as each stage follows in a hierarchical integration of what there was before, the higher stages do not replace the lower, rather, they reintegrate them.2
In his study, Kohlberg addresses the moral reasoning of children, adolescents, and adults, through an interview on moral judgment consisting of three hypothetical dilemmas, each dilemma involving a character who has to choose between two conflicting values, for example, the value of life against the value of the law, or the value of authority against the value of the contract. The answer is how the character should resolve the dilemma and why that would be the best course of action. The primary interest of the analysis focuses on the form or structure of the individual’s reasoning and not the specific content of their thoughts.1,2
Especially when facing dilemmas that arise in daily life, the exercise of moral judgment as an integral part of the thought process lets one extract sense from moral conflicts and reflect on the values themselves and arrange them in a logical hierarchy.
Preconventional, conventional, and postconventional levels of moral development constitute three different types of relationship among the individual, the rules, and society’s expectations. In addition to this social perspective, each level and each stage is defined by a set of values (what is considered right or just) and a set of reasons to support what is right, where the starting point for moral judgment is according to the level in question.
Other authors have studied moral reasoning from the category of prosocial reasoning, understood as "...behaviors of how to help, comfort, or share... that is, those behaviors that benefit others without seeking reward for their actions".2 The study of prosocial behavior by Nancy Eisenberg is based on dilemmas in which prosocial behaviors require decision-making at risk to oneself; helping behavior is basically a moral act that is not normally governed by social norms, therefore it is a personal or collective decision, since there is no moral or legal obligation requiring such behaviors.3 In the definition of prosocial behavior, the only controversy is based on the fact of differentiation between prosocial and altruistic behavior. In general, there seems to be agreement in calling prosocial behavior those behaviors carried out voluntarily to help or benefit others, such as sharing, support, and protection. On the other hand, altruism involves prosocial acts carried out for internal reasons or values without seeking any external reward.3,4
The highest level is the category of human dignity and equal rights for all individuals; this frame of reasoning seems helpful in the field because of the excellence of Care in Vulnerability, that is, the principle of vulnerability is directly related to care and the idea of responsibility; there is an imperative: "in the face of the vulnerability of others one cannot remain passive and immutable, but must respond in solidarity. I must do everything I can on my part to mitigate that vulnerability and help others to develop their personal, physical, moral, and intellectual autonomy".5
Nursing is the profession that has the privilege of being with the person in fragile situations to provide physical and spiritual comfort, as a differential humanistic value; issues such as transcendence and death are close possibilities in extreme situations, and the need for care is evoked. In some of her works Vera Regina Waldow says that care is relational, always depending on the other; in nursing, the other is the person and their family, those who need their care, including everything around, the context, the environment, and the influences derived from it in the complex interaction with the environment. She expresses it more broadly:
"It is a way to live, to be, to express oneself. It is an ethical and aesthetic posture towards the world, or rather, a commitment to being in the world and contributing to the general welfare, the preservation of nature, promoting the potentialities of human dignity and spirituality. Care is, ultimately, contributing to the construction of history, knowledge, and life".
One no less important aspect to consider is the culture of each nurse in relation to their own beliefs, which intertwine with other subcultures inherent in the context. To address possible cultural barriers during the therapeutic relationship, it is necessary to develop or enhance "cultural competence," which is defined as the complex integration of knowledge, attitude, and skill that increases communication between different cultures and appropriate or effective interactions with others. In our case, patient care calls for a complex integration of knowledge with a good dose of attitudinal willingness and ability to listen, in order to perceive the values, beliefs, and attitudes of the people being cared for, and to harmonize them with the other groups involved and their dynamic flow.6 In the same vein, emphasis has been placed on being a "culturally competent" professional in the practice of medicine and nursing in the process of preventive as well as curative care.7
Specifically, the process of care is based on the assumption that individuals of a certain social group have internalized values in the same way, or, in Kohlberg’s terms, are at the same stage of moral reasoning. In everyday nursing practice it is likely for results to be achieved partially or for goals to be missed due to not considering the fluctuating dynamics between values and the stage of moral reasoning of each person to whom help is given. Additionally, Rojas says that "the values officially hierarchized by a society as the most important are not always treated equally by its members. This is because the formation of values in the individual is not linear and mechanical, but goes through a complex process of personal development by which human beings interacting with the historical and social environment in which they operate, develop their own values".8
Ethical decisions and inferences mix in a crisscross of values; by their nature they are abstractions of the concrete practical action of man. Rightfully, "aspiring to justice" is an ideal, whereas in practice, what is exercised is virtues, that "it is fair" in this or that situation. In other words, a value is an abstract field of human achievement that serves as a frame of reference, but upon grounding it or operating it, the results can be different. For example: limiting food is an unjust act to the healthy and developing child; however, in clinical situations, even despite the desire of the infant and those involved in their care, food intake must be limited or suspended. In both cases there is an abstract frame of reference, preserving health and life, but in real operation, we act in the opposite way.
As such an effective nursing intervention should correspond to a correct decision based on a social context (I think/you think) and linked to three fundamental elements, the factual situation, the axiology (duty), and the socialized situation (values of those responsible for the child). The socialization of these values or sharing them is consequently full of catches, for example: there are situations that occur with parents of critically ill newborns, which are perceived as "valuable offspring", such as cases of only children, those conceived with extreme difficulty, and the children of difficult pregnancies, among others.
Such situations often exacerbate expectations that people have of the potential of care, the assessment of the child, projecting onto it unrealistic expectations, sometimes expressions of "you can," "you are stronger than others," "we love you the most," or others that suggest expecting a response out of the range of possibility, where parents discover that their expectations do not match reality and that their child is as vulnerable as any other.
Due to this, nursing interventions in the field of pediatrics must have an unavoidable philosophical and ethical framework; the starting point is to have a clear conception of human development (axiological load) that mixes the subjective and the objective. These elements yield a general frame of reference underpinning the rules or guidelines for a technically feasible and humanly honest and legitimate intervention; that is, for the good of the people, the family, and the social group to whom it is directed.