Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts

Related Issue: "Nursing Around the World"

In a recent article, Heller, Oros, and Durney-Crowley (2000) note 10 trends to watch regarding the future of nursing education. The first trend listed relates to diversity and its impact on disease and illness and the subsequent challenge to change education and practice to be congruent and respectful of differing values and beliefs. In a like manner other authors (e.g., Bellack& O'Neil, 2000; Gibson, 2000 ; Hegyvary, 2000; Outlaw, 1997) have called attention to the need for closer scrutiny of our values and beliefs about diversity. Outlaw, for example, expressively requests "a call for scholarly inquiry on human diversity" (p. 69). 

Implicit or explicit in the works of these authors are the notions of culture and of values. Both words have many interpretations but each word has a primary association with a discipline. Culture's primary homebase is anthropology. Value's primary homebase is philosophy, especially as it relates to ethics. One can identify subsets of words associated with each. For culture, terms that immediately come to mind are ethnocentrism, cultural imposition, cultural importation, and cultural exportation. (See definitions and assumptions) For values, terms that immediately come to mind are belief systems and norms. The rubber meets the road when the two terms are joined: cultural values. Therefore, our purpose in writing this article is threefold: a) to clarify the relationships among cultural values, ethics, and ethical conflicts; b) to demonstrate with examples from the culture predominant in the United States how cultural attitudes and values in nursing may lead to conflict as a result of increasing globalization, and c) to formulate nursing strategies to decrease ethical conflicts related to cultural values.

Cultural Values, Ethics, and Ethical Conflicts

Cultural values refer to enduring ideals or belief systems to which a person or a society is committed. The values of nursing in the States are, for example, embedded in the values of the U.S. American culture with its emphasis on self-reliance and individualism (Davis, 1999). Basic to the value placed on individualism are the beliefs that "individuals have the ability to pull themselves up by their bootstraps" and that an individual's rights are more important than a society's. 

However, many cultures do not share the primacy of the value of individualism. Consider the factual data presented by Davis that about 70% of all cultures are collectivistic (i.e., loyalties of a person to a group exceed the rights of the individual) rather than individualistic (i.e., the rights of the individual supercede those of the group). "With individualism, importance is placed on individual inputs, rights and rewards" (Andrews, 1999, p. 476). In many cultures, health decisions are not made by an individual but by a group: family, community and/or society. Socialized medicine or government sponsored health care for all residents is reflective of the value placed on collectivism.

Therefore, reflecting on the values that predominate in the culture you practice, attain an education, visit, or read about is a requirement for ethical thoughtfulness. Ethics has many definitions but, typically, ethics is viewed as a systematic way of examining the moral life to discern right and wrong; it also requires a decision or action based on moral reasoning. Ethical conflicts occur when a person, group or society is uncertain about what to do when faced with competing moral choices (Silva, 1990). Ethical conflicts and issues occur within or among cultures and are usually precipitated by cultural/subcultural values in opposition. 

Conflict and Globalization

Certainly members of any culture may hold varying degrees of commitment to the predominant values of the culture, but being in opposition to those values sets the stage for conflict. Even countries where people were once relatively isolated from other cultures or were homogenous (e.g., Asian cultures) are also becoming more culturally diverse. Why? Through increased communication, travel, and trade, differing perspectives have been imposed upon the cultural beliefs and ethical values of people because they are believed to be right or better (ethnocentrism at work). For example, North Americans and others with Western ethical perspectives who live in their own homelands may, unwittingly, export products abroad like textbooks, curriculums, and used equipment. These products, even though well intentioned, may present a cultural imposition. In addition, the altered attitudes of international students who return to their homeland after a westernized education in a capitalistic culture are a source of inculcating new but perhaps unsettling ethical perspectives on a country or profession. Globalization, with its outcome of increased cultural diversity, has not only given nurses pause for thought but also has contributed to ethical conflicts. 

Davis (1999) recognizes how ethical conflicts and issues can arise, especially when nurses acknowledge the profound influence that the values of nurses in the United States have had on other countries worldwide. The value on individualism, for U.S. nurses, for example, can be examined in relation to the ethical principles of autonomy and justice. The ethical principle of autonomy is related to self- determination, that is, the individual's right to make decisions for him or herself. Consistent with this principle is respect for the autonomy of others. Therefore, the lack of respect for the decision-making of culturally diverse people in nursing practice is unethical.

The other principle, justice, which deals with what is due or owed to an individual, group, or society, has numerous definitions. For this discussion, we focus on two conflicting material principles of justice that cause ethical conflict: 1) "to each person according to what can be obtained in a free market, " 2) "to each person based on need." 

The first material principle of justice has autonomy as its underpinning. It is in keeping with a supply and demand situation where some persons will possess or benefit more than other persons. A problem with this principle is that it can lead to inequalities in society's burdens and benefits.

The second material principle of justice has fairness as its underpinning. It is sensitive to individual differences and to factors over which the person has no control. A problem with this principle is how to honor it when resources are finite or scarce.

While we have only examined ethical conflicts that evolve from the U. S. cultural emphasis on individualism and the related ethical principles of autonomy and justice, there are many other examples of conflicts that can be and should be examined, but go beyond the scope and purpose of this column. However, we leave the reader with two questions to consider that are particularly cogent to a discussion on ethical conflicts: "'¦is it justified to strive for uniformity of nursing practice on the basis of ethics across all cultures?" and "'¦are there ethical notions of caring, ethical principles and virtues, that could be endorsed as true for all nurses everywhere?" (Davis, 1999, p. 123). 

Nursing Strategies to Decrease Ethical Conflicts Related to Cultural Values and Diversity

Of the many nursing theories used in the United States today, the one most associated with culture and cultural values is Leininger's (1991) Culture Care Diversity and Universality: A Theory of Nursing. In the mid-1950s she first observed that nursing practice lacked attention to cultural and humanistic factors. It was from these observations and from further writing and research on the topic that the preceding book was written (Leininger, 1996). Implicit to her theory is the importance of communication between patient/client and the provider(s) of care. As Donnelly (2000) succinctly states, "...ethical issues become more prominent when a lack of communication occurs" (p. 124). Lack of communication is more likely to occur when nurses care for international and culturally diverse persons. The resultant misunderstandings can lead to lack of respect for persons whose cultural values are different from one's own and to potential and real harm to those persons, whether culturally, psychologically, physically, or spiritually.

How can the situation be improved? Here are some suggestions to improve communication and nursing care and, thus, decrease ethical conflicts:

1. Recognize that values and beliefs vary not only among different cultures but also within cultures. 
2. View values and beliefs from different cultures within historical, health care, cultural, spiritual, and religious contexts. 
3. Learn as much as you can about the language, customs, beliefs and values of cultural groups, especially those which you have the most contact. Related Links from Transcultural Nursing: Basic Concepts and Case Studies Available: www.culturediversity.org/links.htm. 
4. Be aware of your own cultural values and biases, a major step to decreasing ethnocentrism and cultural imposition. (A questionnaire that can help you with this goal can be found in Andrews and Herberg, 1999). 
5. Be alert to and try to understand the nonverbal communications of your own and various cultures such as personal space preferences, body language, and style of hair and clothing. 
6. Be aware of biocultural differences manifested in the physical exam, in types of illness, in response to drugs, and in health care practices.

Terms & Definitions

Ethnocentrism - A person's belief in the inherent superiority of one's own culture over that of other cultures.

Cultural Imposition - A situation where one culture forces their values and beliefs onto another culture or subculture.

Cultural Importation - A situation where one culture buys or brings in products and goods from foreign countries (cultures) to be used or sold in the importing culture.

Cultural Exportation - A situation where one culture sends products or goods to foreign countries (cultures) to be used or sold in the exporting culture.

Belief Systems - A totality of enduring facts, principles and values that a person or a  culture deems to be true or to be trusted.

Norms - Standards that are accepted, often implicitly, by a culture.

Assumptions

1. Goods or products imported/exported intact to another culture may not meet the needs of that culture or therefore, may need modification. 
2. Both ethnocentrism and cultural imposition show insensitivity to the culture(s) who receive them. 
3. Both belief systems and norms are needed for a stable culture.

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