doi: 10.1111/nup.

12063
Original article

Virtue ethics and nursing: on what grounds?

Roger A. Newham DMedEth

Senior Lecturer, Society and Health, Buckinghamshire New University, London, UK

Abstract Within the nursing ethics literature, there has for some time now been a
focus on the role and importance of character for nursing. An overarch-
ing rationale for this is the need to examine the sort of person one must
be if one is to nurse well or be a good nurse. How one should be to live
well or live a/the good life and to nurse well or be a good nurse seems to
necessitate a focus on an agent’s character as well as actions because
character is (for the most part) expressed in action (e.g. see Laird). This
paper will give an overview of the reasons for the role and importance of
character in nursing practice and explain its relation to nursing’s fre-
quent use of virtue ethics in order to recommend caution. While the
paper agrees that the role of character is important in nursing caution is
needed in both how much moral and thus normative, emphasis is being
placed on the psychology of character and on the drift to virtue ethics.
The psychological which may be explanatory needs to be linked with the
normative, and a justification for the normative is needed. A justification
as virtue ethics is contested, and nursing practice does not need to take
on this explanatory and justificatory burden.
A tentative proposal raised but not discussed in depth in this paper is
that when an ultimate explanation or explanatory ground is needed,
nursing practice leads quite naturally to a form of consequentialism as
well as a realist metaethic. On this account, there are two levels of moral
thinking, and nursing practice entails the virtues at one level and leads
quite naturally to moral thinking at another more critical level of the
criterion of what makes something right and good independently of
character.

Keywords: phronesis, moral theory, agency.

Correspondence: Dr Roger A. Newham, Senior Lecturer, Buckinghamshire New University, 106 Oxford Road, Middlesex, London
UB8 1NA, UK. Tel.: 01494 522 141 ext 4431; fax: 01494 522 141 ext 4431; e-mail: roger.newham@bucks.ac.uk

40 © 2014 John Wiley & Sons Ltd

Nursing Philosophy (2015), 16, pp. 40–50

Introduction
Within the nursing ethics literature, there has for
some time now been a focus on the role and impor-
tance of character for nursing. An overarching ratio-
nale for this is the need to examine the sort of
person one must be if one is to nurse well or be a
good nurse. How one should be to live well or live
a/the good life and to nurse well or be a good nurse
seems to necessitate a focus on an agent’s character
as well as actions because character is (for the most
part) expressed in action (e.g. see Laird, 1946). This
paper will give an overview of the reasons for the
role and importance of character in nursing practice
and explain its relation to nursing’s frequent use of
virtue ethics in order to recommend caution. While
the paper agrees that the role of character is impor-
tant in nursing caution is needed in both how much
moral and thus normative, emphasis is being placed
on the psychology of character and on the drift to
virtue ethics. The psychological which may be
explanatory needs to be linked with the normative,
and a justification for the normative is needed. A
justification as virtue ethics is contested, and nursing
practice does not need to take on this explanatory
and justificatory burden.
Though nurses are ‘doing moral theory’ when they
examine issues in practice, such as truth telling
(MacIntyre, 1984), for the most part, the work of
nursing is clearly moral by any theoretical light.
However, nurses can and should give substantive
reasons, when they need to, for what they do, and for
the most part, these can be given fairly easily without
recourse to an explicit, ultimate ground. However,
where giving reasons for practice proves difficult to do,
traditional moral theories, unlike virtue ethics, provide
an objective ground for reasons. They provide criteria
of what makes something good or right, or virtuous.
That is, they can provide an account of both character
and normativity. They can also accommodate a virtue
theory and the idea of phronesis and so accommodate
the importance of character while recognizing that
there is something the phronimos, and thus, having
moral character as virtue gets right. Having a good or
virtuous character and having phronesis does not
make things right or good.
© 2014 John Wiley & Sons Ltd
Nursing Philosophy (2015), 16, pp. 40–50
Virtue Ethics and Nursing 41
A tentative proposal raised but not discussed in
depth in this paper is that when an ultimate explana-
tion or explanatory ground is needed, nursing practice
leads quite naturally to a form of consequentialism as
well as a realist metaethic. On this account, there are
two levels of moral thinking, and nursing practice
entails the virtues at one level and leads quite natu-
rally to moral thinking at another more critical level
of the criterion of what makes something right and
good independently of character.
An overview of character and
nursing practice
Nurses usually care for or/and about ill and especially
vulnerable people and that such caring is related to
both the character of the nurse as well as actions and
that both are moral concerns. Nursing is claimed to be
a moral profession, and the good and excellent nurse is
or must be a good and moral person (Pellegrino &
Thomasma, 1993; Connor, 2004). To be such a person
necessitates a focus on character. It is said that a
greater focus on the agent and character than has been
given in traditional moral theories (or at least by theo-
rists) is needed for nursing to be effective. At a very
general level, to be effective in nursing is to provide a
‘holistic’ form of health (Whelton, 2002; Armstrong,
2007). This may form nursing’s ‘function’ or end for
which good character and virtues are necessary to
achieve excellence (Pellegrino & Thomasma, 1993;
Begley, 2008). More specifically, to be effective
includes such thing as being able to form therapeutic
relationships with patients that includes listening to
narratives of their illness (Armstrong, 2007) and
understanding (in some sense) their emotions (Scott,
2000). Ekstrom (2012) has an insightful discussion
about this based on a medical case study about how a
lack of compassion, a fault in the agent’s character, can
result in poor medical treatment and disastrous out-
comes. Like current UK, nursing she calls for the need
for educational improvements to encourage and thus
improve character. Ekstrom is actually writing about
the need for the virtue of compassion as the disposi-
tion to experience the emotion of compassion at the
right time and towards the right ends etc.The compas-
sionate person has an ‘effective impulse’ leading a
42 Roger A. Newham
person to assist in the recognized suffering of another
(ibid., my emphasis).Two things are important to note.
One is the claim that nurses need education in com-
passion. The type of education is plausibly not meant
to be theoretical but habitual in a sense to be
explained below in relation to the virtues. The second
thing is that on this account, one cannot experience
compassion if one does not believe the agent is suffer-
ing, and one needs humane engagement to enable this,
such as listening to the patient’s narrative and making
sense of their expressed emotions. However, what
takes priority here, the belief that someone is suffering
or the emotional experience? In Ekstrom’s case study,
one set of doctors did not believe in the stated symp-
toms and thus did not believe the expressed emotions.
The doctors who did were very highly specialized and
whose knowledge meant they did believe the symp-
toms and so did believe the expressed emotions. The
case study does not show by itself that one set of
doctors provided humane engagement as displaying
emotions and not the others or that it was humane
engagement as a display of emotion that made the
difference rather than beliefs. Further, as just men-
tioned, the case study was about the virtue of compas-
sion not a mere feeling or emotion. This makes a
difference, and it may be that the virtue of compassion
includes the emotion or feeling only slightly if at all
(Crisp, 2008). This may not seem to detract from a
focus on the agent’s character as having the virtues is
still part of one’s character. A reply is that this is true
but that much of the resurgence of interest in virtue is
the idea that it accommodates a person’s emotions.
Another reply is that the need for emotions as part of
one’s character is also meant to be a moral one; they
are a part of what it is to have a good character needed
to get things morally right.
A further need for character in nursing has to do
with the point that (moral) principles and (moral)
rules do not apply themselves; it takes moral agents to
do this with an awareness of the particulars of the
situation, and so, it is crucial to examine the sort of
nurse, one which means examining their character
(Armstrong, 2007; Begley, 2008). The need (neces-
sity?) for good character has something to do with
both motivation and an ability to get things right in
practice. There is a sort of ‘internal imposition’ of the
agent who is a nurse such that he reliably as charac-
teristically tells the truth, is patient with patients, and
will do and be so when no manager or relative is
around to observe (Pellegrino & Thomasma, 1993;
Begley, 2008). So, a general idea is that the virtuous
person is motivated to act reliably. One way to explain
a sense of reliability which seems to bring out nicely
the need for character is in relation to trust. However,
it also points out a problem.
The notion of reliability implies some degree of
trust in the nurse by patients especially if there is a
knowledge gap and the patient is particularly vulner-
able. It may be claimed patients are ‘forced’ to trust or
to at least rely on the nurse and that such reliance may
just be the patient taking a rational but calculated risk
in the situation. Trust can however be understood
more as an emotion, as an ‘effective attitude’ (Lahno,
2001) and so not subject to direct, rational control.
The way one sees the world, a seeing as, is effected by
the emotional attitude. Different attitudes to seeing
the world can result in different actions (ibid.). But a
problem looms. What if the nurse’s attitude differs
from the patients? The nurse will see the world dif-
ferently. In response, it can be claimed that it is virtue
we are talking about, and to be a virtue means getting
the action and feeling right. I think this does not solve
anything, and it will be discussed further below
though it is connected with the next thing about the
need for character in nursing practice the idea of
getting things right. What is the knowledge, as getting
things right, needed for nursing work?
The ‘work’ of nursing includes the knowledge of
nursing and its practice in particular situations. On
this moral and ‘particularist’ account, knowledge may
be praxis (good action) rather than poesis as technè
(production) (Connor, 2004). Perhaps a minimal level
of competence for a nurse is to have technè, such as
being competent in the technique of using a blood
pressure machine, but praxis is needed to be a good
nurse or an excellent nurse; using the machine well on
and with a particular patient at a particular time.
Something that cannot be learnt in a classroom nor
even be completely taught by instruction and of which
there is no end to the learning (hence, the concern
raised above about claims for the need for the educa-
tion of nurses in emotions such as compassion). In
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Nursing Philosophy (2015), 16, pp. 40–50

short, praxis is a different type of rationality for action
or at least an extension of how the term is commonly
understood roughly as scientific cause and effect and
useful for prediction and control of nature. On such
an understanding, problems can be anticipated and
thus planned for in advance, being contained in the
general formulae and just needing application
(Dunne, 1999). Objective, technical rationality means
the role for judgement is minimized and possibly even
ideally dispensed with (ibid.). But praxis requires
judgement of the particular bringing in application of
the general as and when required.
The notion of praxis as excellence resonates with
Aristotle’s phronimos and hence the link (again) with
good character and or as moral virtues especially in
order to get things right (or act well). Not just anyone
can get moral matters or actions right unlike (it is
claimed) learning maths or a scientific formulae where
once you have had some technical training, a young
child or murderous criminal could become an ‘expert’
(Hursthouse, 2011). It is necessary to emphasize the
term moral because the particularist claim used in
nursing is generally about moral actions citing
McDowell’s (1979) use of Wittgenstein’s rule follow-
ing problem, but Wittgenstein’s point is about all rules
(Crisp, 2000). This point lessens the force of a version
of a particularist claim that moral knowledge is differ-
ent in type to other forms of practical knowledge. So
knowledge of nursing practice could be both moral
and nonmoral and still require judgement. Aristotle’s
analogy of virtuous or moral knowledge with medicine
however does make such a distinction; medicine is a
technè not praxis. Perhaps it is almost praxis and
perhaps it could be argued that to practice medicine
well or excellently needs praxis as morally good action.
If nursing knowledge is praxis, then character as
having virtue seems to be necessary for an openness to
learning which moves beyond experience (ibid.) and
towards good action. Good action as character as
virtue seems to be necessary for nursing practice. This
is important in that from what has been said so far the
need for good character seems clear but not the sense
of good or morally good.The next section will examine
how character is related to virtue which will lead natu-
rally into a distinction between virtue ethics and virtue
theory regarding the morally good.
© 2014 John Wiley & Sons Ltd
Nursing Philosophy (2015), 16, pp. 40–50
Virtue Ethics and Nursing 43
Character and virtue
The notion of character used in many accounts of
virtue is a fairly technical one involving a number of
interrelated ideas. The character relevant for being
virtuous is (ideally) something that is a fixed and per-
manent disposition or state (Aristotle tr. 1980;
Hursthouse, 1999). The settled state of one’s virtuous
character comes, if it does (it is plausible that Aristo-
tle did not hold out much hope for most of us who
need the rule and enforcement of law), only after
many years of adulthood and also being brought up
‘correctly’ or well (Burnyeat, 1980). What one learns
is at first through rote and following ‘moral exem-
plars, learning “the that” and eventually one learns
“the because” ’ (Burnyeat, 1980). Understanding the
idea of ‘the because’ is a crucial issue for this discus-
sion, and it leads directly into the next section about
virtue ethics and virtue theory, so more will be said
there. But for now, one point to note about the rela-
tionship between character and virtue as a settled
state to indicate a sense of ‘the because’ is useful.
Having the virtue of say honesty seems mean that for
instance, a tradesman (or nurse) would not cheat or
be dishonest if it appeared it would make a profit. But
this understanding of the character trait of honesty
would I think still be or show an honest character if
the tradesman (nurse) knows that honesty is a good
business (nursing) asset (Laird, 1946).
For Aristotle and Hursthouse among many others,
the fixed and permanent disposition or state of virtue
entails (in some sense of entail, probably not logical)
acting (being in a certain state) and feeling (including
the emotions and desires). Having character as virtue
includes emotions, and nursing practice makes much
of the appropriateness of the emotions to nurse well
or excellently (Scott, 2000). The understanding of the
appropriateness of the emotions is vital but a very
difficult one to grasp, and this is discussed below
under virtue ethics and virtue theory but it is clear
that some virtues can be primarily characterized in
terms of emotion and others primarily of action
(Laird, 1946; Crisp, 2010).
A character trait to be a virtue rather than a vice
disposes one to act rightly, hence the idea of ‘moral
character’ or moral character traits (Brant, 1970).
44 Roger A. Newham
Some accounts of virtue would deny a role for deontic
concepts (Armstrong, 2007), but it is unlikely that the
sense of right and ought would change (Crisp, 2004).
The doctrine of the mean shows how both actions and
feelings are involved in the idea of getting things
right, as acting virtuously, and it can highlight the
complexity of morality with many things to get right
including the emotions; there are many ways also to
go wrong (Crisp, 2010). So, when character is under-
stood as virtue, it automatically involves having good
character as well as getting things right in practice.
Though the fully virtuous person, the phronimos, with
a settled state of character (by definition) gets things
right and possibly sets an epistemological standard,
she does not make things right. What does make
things right can be explained in both normative
theory and metaethics.
Virtue ethics and virtue theory
Within the nursing ethics literature, the reasons for
the resurgence on the role and importance of charac-
ter often follow the same themes in moral philosophy
which claim that within traditional moral theories
(understood broadly as especially based upon Mill
and Kant), there has been a lack of the importance of
character as well as agent relative concerns and that
moral theory needs to reclaim them (e.g. see
Trianosky, 1997 and Athanassoulis, 2013 and for a
nursing ethics focus Armstrong, 2007). Nursing may
have specific aims, requiring good (moral) character
for being a nurse or at least for being a good nurse,
but ultimately, such aims are of a moral nature, and so,
at this general level, the link with the themes in moral
philosophy are not wrong. As discussed above, the
idea of character is taken to be closely linked with the
virtues, and the debates within moral philosophy
include how character and virtues can be (and have
been) accommodated by consequentialist and deon-
tological theories as well as a development of a third
type of theory, virtue ethics.
Virtue ethics may still be thought of as a term of art
because there are varieties of virtue ethics (Walker &
Ivanhoe, 2007). Though there are varieties, an impor-
tant general distinction can be made between virtue
ethics and virtue theory (Driver, 1996; Armstrong,
2007; Athanassoulis, 2013). Roughly, the former
(especially in a pure, monistic form) is a normative
theory where rightness is defined in terms of, or just is,
virtue but not vice versa, and the latter is an account
of the role virtues have in a particular normative
theory. A better distinction between virtue ethics and
virtue theory can be made following Crisp (2010) via
two levels of normative theories: substantive and
explanatory. The former is about how one should live
and the latter why one should live that way. An
explanatory virtue ethics would need not only to say
‘lead the life of virtue’ but also the ultimate reason or
(non derivative) grounding reason for doing so
should be provided by virtue (ibid. p. 23). Crisp (2010)
in a footnote makes a very helpful clarification about
such grounds that the virtue of an act itself counts in
favour of the act.Though this can helpfully distinguish
a virtue ethics from virtue theory, as Crisp points out,
it leaves open which character traits count as the
virtues. This proves to be a particular pressing
problem for virtue ethics which must rely on charac-
ter.What character traits constitute a virtue? How can
we validate our beliefs as to which character traits are
virtues? This seems especially pressing if emotions are
part of what we need to get right.
Burnyeat’s (1980) account of how one develops or
learns to be virtuous the notion of ‘the because’ which
comes after the habitation as ‘the that’ within virtue
ethics is not meant to be independent from virtuous
character as it could be in an objective goods account.
A virtue ethics understanding of the development of
character traits such as kindness and kind outcomes
for instance is valued because it is part of virtue
(Athanassoulis, 2013). So although at a general level
of abstraction this distinction between virtue ethics
and virtue theory seems correct, defining virtue ethics
is much more complex than this division suggests
(Swanton, 2013). In part, this is because virtue ethics
must have an essential reference to virtue as an endur-
ing state of a person’s character and different
accounts of virtue ethics differ on what sort of char-
acter is to count as a virtue.
The difficulty in giving an account of a virtue ethics
in general is reflected in the nursing ethics literature
about the need for a focus on character and virtues.
Some, such as Armstrong (2007), explicitly claim to be
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Nursing Philosophy (2015), 16, pp. 40–50

using a ‘strong’ virtue ethics, probably not a pure
monistic account but an explanatory virtue ethics and
as a distinct normative theory. Armstrong’s (2007)
book-length study of the virtues in nursing practice
spends a chapter discussing the problems for ‘tradi-
tional’ moral theories and the rest expounding the
advantage of a virtue ethics approach specifically for
nursing practice.Though he makes a great use of Aris-
totle to support his claim of the need for a virtue
ethics for nursing, it is contested as to whether Aris-
totle should be so used (Buckle, 2002). Notably, this
strong version as virtue ethics claims the justification
of acts is ‘couched’ in virtue terms (Armstrong, 2006,
p. 118). So, acts somehow are justified by character
traits of agents as virtues. Psychology seems to be
justifying and not just explaining actions.
But it can be questioned if Armstrong’s account is
really a virtue ethics (ignoring the question of the use
of Aristotle as holding a virtue ethics). His approach
follows Hursthouse and MacIntyre. He follows
Hursthouse (1999) especially in critiquing other
moral theories but also her (Anscombian) use of
virtue rules to provide action guidance and character-
ization of the virtues in terms of an agent’s character
traits. But Hursthouse does not justify acts by an
agent’s character. The theory (the last third of the
book) does appeal to an objective account of the good
on which the virtues depend, and she admits her
account of right action is ultimately (though perhaps
not viciously) circular (see Hursthouse, 1997 footnote
2 and Begley, 2005) and that many virtues depend on
the idea of the good. Armstrong uses MacIntyre’s
(1981) After Virtue account of internal goods for
nursing practice which seems to be ultimately inde-
pendent from character or suffers from moral relativ-
ism as the later MacIntyre admits. So, Armstrong’s
virtue ethics could be understood as a virtue theory
with perhaps explanatory and justificatory benevo-
lence. I think he would deny this, based (in good part)
on implications from his critique of traditional nor-
mative theories and claim that character and virtue
cannot be really understood by them. But here lies a
real issue, apart from his claim about justification, the
rest of the support for a virtue ethics is based on issues
to do with decision making including motivation,
emotions, beliefs, etc., all things which do involve the
© 2014 John Wiley & Sons Ltd
Nursing Philosophy (2015), 16, pp. 40–50
Virtue Ethics and Nursing 45
agent and in some sense his character. But these are
things which, despite Armstrong’s criticism, tradi-
tional theories can and do take account of, plausibly
to the right extent.
Begley, calls her approach variously virtue based
(Begley, 2008) and virtue centred (Begley, 2005),
claiming it is midway between a radical replacement
version (a virtue ethics) and a supplementary
account. So, it is actually unclear if Begley’s approach
is a virtue ethics or virtue theory, but it is likely to be
a virtue ethics because of the dissatisfaction with tra-
ditional normative theories for nursing. A particularly
important aspect of virtue ethics is the character of
the virtuous person who behaves well consistently
and has a disposition to do so (Begley, 2008, p. 338).
Even if a virtuous person does not know the rules, he
will still not do bad things because of his disposition to
act well (ibid., my emphasis). Much or indeed every-
thing hangs on this idea of acting well/rightly because
of one’s disposition (or trait). The connection
between not acting badly and one’s disposition is not
a necessary connection. The idea may be plausible if
not knowing is meant as not explicitly citing rules or
giving reasons at the time of acting and so a sort of
tacit knowledge or ‘habitual’ as ‘second nature’ action
(where habit is not mindless repetitive action or reac-
tion), but there must be something recognized as
good that guides his action and provides an account of
what makes an action normative. While it is stipula-
tive or true by definition that a practically wise person
will not act badly or get things wrong, it must be ideal
because of the contingent human nature, and even for
such a phronimos, there must be something that is
right the phronimos does not make it right. If this is
near correct, then this need not trouble an explana-
tory consequentialist and substantive virtue ethics,
providing the necessary account between psychology
and the normative and ultimate justification.
The psychology as character includes beliefs and
emotions. There are two particular issues related but
ultimately distinct. One is about the need for or the
prominence of the emotions or affect in virtue as
getting things right morally. The other has to do with
the relation of a human being’s psychology generally
as beliefs, desires and emotions and how they link
with normativity. Emotions are meant to be under-
46 Roger A. Newham
stood to be more than instinctive reactions to inde-
pendent facts or situations. They are meant to actually
affect the understanding of situations or certain
(types of) facts. So, emotions are on this account nec-
essary for (full) understanding of moral issues; they
are a necessary causal part of full understanding
(Starkey, 2008) or conceptual part of full understand-
ing and awareness (McDowell, 1979; Wiggins, 1980).
One’s emotional awareness of an object say is unique
to the emotional state and different from an unemo-
tional awareness of the object (Starkey, 2008). So,
an experience of an event with an accompanying emotion
may change the experience of the state of awareness of the
event itself and as result of this procedure produce an under-
standing of the event that is not possible without the
emotion. (Starkey, 2008, p. 430)
Starkey’s account of the necessity of the emotions
for virtue and character involve a cognitive and affec-
tive element. Neither on its own is sufficient for
understanding character for ethics, but what the rela-
tionship should be is much contested. Starkey distin-
guishes what he calls apprehension from belief states
and perceptual states so that the emotional apprehen-
sion is phenomenal, a sort of ‘seeing as’ and yet it does
not, or rather is not meant to, support emotions as
noncognitive. But it is unclear how they can be what
he claims they are and be cognitive. A phenomenal
account of ‘seeing as’ is different from a reflective
judgement that something is the case or is good. It is
more likely that the emotion as noncognitive feeling
provides motivational support for the cognitive judg-
ment. But what we are after here is how emotions
support the cognitive and objectivity as getting things
right and how such phenomenology relates to ratio-
nality and reality.
Starkey’s claims are like much earlier discussions
about the rationality of the virtues. On a virtue ethics
account, one’s character is part of having desires and
beliefs such that rationality in virtue ethics is to be
understood as denying a distinct separation of the
rational with beliefs and nonrational with desires
(McDowell, 1979; Hursthouse, 1999). However, on
Starkey’s (2008) account, the idea of awareness and
understanding can diverge as when one knows a
snake is not dangerous but one’s awareness is one of
fear nevertheless. What is the feeling of fear adding to
the knowledge of the situation? Explanations may be
given regarding evolution and survival, but what we
need is normative as getting something right and
acting as one ought. Full understanding comes when
awareness and understanding converge with an
appropriate understanding of the situation (Starkey,
2008). This or a similar sense of appropriateness for
value is vital but a very difficult one to grasp in the
literature by McDowell and Wiggins, both of whom
are frequently mentioned in the nursing literature as
providing support for virtue ethics. When trying to
avoid subjectivism and relativism, Wiggins labels his
account ‘a sensible subjectivism’ (Wiggins, 1987) and
McDowell (1979) relies on a ‘whirl of organism’.
Starkey (2008, p. 440) I think also leaves the problem
of relativism hanging when he claims that the criteria
of appropriateness include ‘our larger values, inter-
ests, concerns and goals (i.e. things that relate to our
thriving)’.
Starkey unlike McDowell and Wiggins admits that
it is not a conceptual question as conceptually full
understanding need not necessarily include emotion
but it seems to be shown empirically. But whether
causal or conceptual, an account is needed of how the
account of character which includes emotions or sen-
timents necessary for virtue can be cognitive and
objective, avoiding relativism. In fact, the account is
likely to need to be conceptual because of the way
empirical studies must collect their data. Such studies
might (though it seems likely that so far they have
not) explain a virtue ethics account of virtuous action
but seem not to be able to justify it.
Though an understanding of character dispositions
or states, as referrals to the person’s moral character
and the facts of their decisions, may help explain
action by showing what (we think) the agent saw as
salient at the time of acting, they cannot be used so
easily by the agent to explain her own actions
(Moreau, 2005) First, the agent himself will not, or
should not, claim he is acting from say compassion
because to do so will definitionally at least prevent
him from acting on ‘true’ compassion. Second, from
the agent’s perspective, it may seem too third per-
sonal to explain what he really was aware of to a third
person in virtue character terms (Moreau, 2005).
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What is needed is something like reasons as facts
belonging to objects so perceived.
The account of the role and importance of character
traits is as dispositions to respond to reasons other
than facts about our characters.The normative force of
disloyalty for instance does not seem conditional on
anything you would do or feel or even desire (Moreau,
2005). For example, we are passive with regard to some
nonmoral dispositions such as arachnophobia, which
are just (brute) facts about how we tend to be moved,
in a way in which we do not regard moral incapacities,
and so they are not/cannot be input to deliberation. ‘I
cannot do that, it would be disloyal’ are inputs and
ones we expect reasons can be given, and such reasons
cannot just be that it is a discovery about one’s psy-
chology rather than the normative (ibid.). Hursthouse
(1999) and Athanassoulis (2013) may stop too soon
with their notion of virtue reasons as ‘the because’ of
justification although Hursthouse does link them ulti-
mately to notions of the good and gives an objective
account of a ground for the virtues turning her account
ultimately into virtue theory.
Some issues for nursing and
virtue ethics
The strong focus on the agent and character via virtues
in virtue ethics is part of how phronesis is to be under-
stood as neither purely cognitive nor purely conative,
noninstrumental mediation between the general and
the particular that needs experience and aesthesis
(Wiggins, 1980; Hursthouse, 1999). The connection
with nursing is that nursing’s rationality is based on
this understanding of the necessity of (moral) charac-
ter, aesthesis and phronesis which very commonly
takes leave from Aristotle’s account of ‘moral’ psy-
chology though not always his understanding of the
ultimate good or final end for quite literally (right
handed) man. Knowing what to do (acting rightly, well
or good) on this account involves a sort of intuition and
of necessity involves practical experience that need
not rely on an algorithmic following of principles and
rules, a form of praxis rather than technè and which by
its very nature is impossible to articulate clearly and
precisely in all of its rich detail (Newham, 2013). This
may be especially so if the character traits of the
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Nursing Philosophy (2015), 16, pp. 40–50
Virtue Ethics and Nursing 47
virtuous person are a complex set of dispositions and
that not all of what one knows can be ‘before the mind’
in intention (Wiggins, 1980).The idea of phronesis and
praxis is well discussed in the nursing ethics (and
education) literature particular with a focus on a
restricted class of ends for nursing (Armstrong, 2007).
The use of ends is problematic for virtue ethicists who
do not subscribe to Aristotle’s metaphysics because
ends are something distinct from the virtue, and it is
particularly problematic for a restricted account of
ends for nursing (Newham, 2012).
There is a further problem with the way a (neo)
Aristotelian use of phronesis can be understood which
is particularly salient for this paper. The phronimos is
an educational exemplar (Kristjansson, 2000),
someone who helps us to learn how to think
(Athanassoulis, 2013) rather than what to think. This
use of the idea of a phronimos can be made by (almost)
any moral theory especially in its connection with the
emotions and character. As Hursthouse in 1997 stated
the belief that there was some special link between the
moral significance of the emotions, character and
virtue ethics are likely to be a historical accident
(Hursthouse, 1997, my emphasis). This is an important
point to note as some excellent papers in the nursing
ethics literature discussing the need for emotional
sensitivity claim that it is ‘downplayed’ in traditional
moral theories (e.g. see Scott, 2000). Much recent work
in normative ethics is showing how there is a room for
emotional sensitivity and so much hangs on what
counts as too much downplaying and what counts as
the right extent. But emotional sensitivity as moral
perception (or awareness) as part of phronesis, it must
get things right. What is right to do is not made right
because of the phronimos; there is something that is
the right thing to do in the situation and many ways to
get it wrong, though by definition the phronimos
cannot go wrong. So, although there are particularities
and no algorithmic procedure to follow to determine
or deduce the correct action and response, there must
be something that counts as the right or good thing to
do, and this is so ultimately irrespective of character.
Normative moral theory provides ultimate reason, and
some are founded on a moral realist metaethic.
Phronesis is also intimately linked with the con-
cept(s) of praxis and particularly as a knowing how.To
48 Roger A. Newham
know how to react and what to do requires aesthesis,
and sometimes, this will need knowledge of particu-
lars that only one very close to the person can know
and plausibly over a long period of time. Stocker
(1976) is a classic example of the idea of the need to
act from virtue especially in intimate, personal rela-
tionships. The epistemic criteria of who is to be said to
have a good character is extremely problematic gen-
erally (Vranas, 2009) and the narrower specification
of good nurse adds further issues of differentiation in
kind if not in ‘intensity’ from having a good character
in general (Newham, 2012). Nursing as a profession
draws a line of ‘professionalism’ distinguishing it from
loving the patient or even friendship with the patient.
Lack of such intimate particulars will affect one’s aes-
thesis and may mean that the agent gets the response
at least not as good as it could have been but also
perhaps wrong. In addition, part of the particulars will
be the patient’s beliefs, wants, desires and emotions.
The idea of a therapeutic relationship in nursing
practice is linked to the idea of nursing’s knowledge
and the need for virtue (Armstrong, 2006) and is
linked to the previous point about how well the nurse
needs to know the patient to provide such a relation-
ship, but in addition, it needs to be remembered that
the nurse is working with and for patients.As patients,
there may well be a certain amount of bias on their
part about the response required by a nurse as to how
much and in what way nurses should care about them
as well as for them. There seems little written about
the idea of a virtuous patient though plausibly virtue
ethics or a virtue account would apply to them as well
as nurses. Noddings (2007) focuses strongly on the
need for responses by the patient or cared for but
denies these need be virtue responses.This could raise
many issues in itself but particularly the idea of what
is to count as appropriate response in particular situ-
ations, especially in a multicultural and morally plu-
ralistic society which may throw into relief more
frequently than homogenous society issues of moral
conflict.
A consequentialist ground
Within nursing, much of the time, things will run
smoothly especially in day-to-day dealings with
others whom the agent need not know particularly
well and when the moral reasons that matter are
open to almost anyone to see (Lovibond, 2007), as
are the technical facts for anyone who has had the
relevant training. For a lot of nursing practice then,
there will be an agreement on what to do and what
should be done by all concerned, including the
patient. This agreement is at one level pragmatic and
intuitive in the sense of not needing to be critically
thought through. Most in nursing and without can
(and do) agree that nursing work achieves for the
most part a specific aspect of the good life. Perhaps
such agreement is all there is or at least can be for us
human beings with our contingent natures, but I
think nursing practice can deliver more, an apprecia-
tion of independent and morally realistic facts.
The novice nurse may stumble over the technical
but need not do so over the moral such as it is good
this patient has his vital signs recorded where the
good is understood as moral as well as technical. Fol-
lowing Lovibond (2007), some constituents of the
world of value declare themselves more or less
impartially to everyone, and though this is from a
section recognizing that other aspects require judge-
ment, much of everyday nursing practice is plausibly
at this more or less impartial openness to all visitors
and patients alike. A good deal of what this entails
will be (the virtue of?) justice. Even where judgement
is called for, where there is a breakdown of habitual
everyday skilful coping (ibid.), all nurses are adults
and have had some ethical formation, and it is plau-
sible that for the most part, there can be an agree-
ment in judgement in everyday nursing practice.
However, there may be a disagreement at the critical
level of what makes something right and good or the
objectivity of morality, but because all agree in prac-
tice, it is not always directly relevant in practice to
debate what this is. But when there is disagreement
or even just reflection on practice and even in prac-
tice, it does become relevant and a virtue ethics
seems to want for an objective criterion of morality/
moral facts that keeps it normative. In brief regard to
deontological-type theories which also highlights the
plausibility of a consequentialist (actually utilitarian
as the article was written before Anscombe’s Modern
Moral Philosophy),
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Nursing Philosophy (2015), 16, pp. 40–50

Indeed, an agent ethics of the usual type tend to neglect its
utilitarian potency and to concentrate its efforts upon the
agent’s intrinsic worth. This may seem a little strange, not
merely because the effects of a man’s deeds upon others
really are important – for however vile a murderous hatred
might be, its effects upon the victim cannot be regarded as
negligible-but also because few moral excellences or defects
are predominantly intrinsic, the great majority being primar-
ily concerned with interpersonal human relationships.
(Laird, 1946, p. 125)
Nursing practice which usually necessitates good
interpersonal relations seems plausibly to lead to a
consequentialist ground and seems to lead naturally
to a ‘dualism of practical reason’ or the critical and
intuitive level of moral thinking (Star, 2011). Most, if
not all, of what nursing practice entails is achieving
good outcomes for patients; nursing’s day-to-day
work generally meshes with intuitive judgements of
what is morally good. The need for virtue theory and
an account of human nature is important as well as
the idea that human flourishing is good. But when
nurses need to provide a ground for their judgements
and actions, a consequentialist one seems most plau-
sible. What makes an action good and what makes a
trait of character a virtue (virtue theory) is the good
effects it produces (Driver, 1996). Consequentialist
theories tend to emphasize the gap between the criti-
cal standpoint and the intuitive (Hare, 1981; Driver,
1996; Crisp, 2010), but nursing practice is ideally
placed to lessen the force of the gap. How a nurse
should be to nurse well or excellently is to be
someone who recognizes suffering and does some-
thing to relieve it. Suffering is the normative term and
can frequently be confirmed by empirical methods
(Copp, 1990). While character and virtues are impor-
tant, they are so because they seem to reliably lead to
good effects. The facts of human need and suffering in
front of nurses daily can provide a naturalist ground
for a realist account of morality that can be a part of
having the virtues. At least such facts seem more plau-
sible as an account of the nature of morality than
expressivism, nihilism or non-naturalist realism. But
this needs remain a stipulation in this paper.
However, it is a stipulation with strong intuitive
backing from experience of and reflection on nursing
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Nursing Philosophy (2015), 16, pp. 40–50
Virtue Ethics and Nursing 49
practice and some theoretical study of ethics. The role
of psychology (of the emotions and beliefs as one’s
character) while possibly having some epistemic
value needs steering by reason, and the reasons are
there to be seen in the suffering and needs of patients,
the alleviation of some of this being the work of
nursing and the alleviation of a good deal more the
work of ‘us’ as moral agents.
Conclusion
Character and virtue are important for nursing prac-
tice, and nursing practice is plausibly a moral concern.
However, caution is needed in the emphasis placed on
the agent’s psychology and the drift to a virtue ethics.
There is something the phronimos gets right.
Epistemically, the virtuous character of nurses may
(but need not) lead the nurse to reliably do good
things. For the most part, nursing practice needs no
explicit justification as for the most part what nurses
do is morally good by any theoretical lights. But when
situations become complex an objective ground for
nurses’ judgements and decisions may be required,
and this seems to follow a consequentialist account. A
consequentialist approach seems to be especially
plausible for nursing as the resultant gap in the
‘dualism of practical reason’ may to some extent be
lessened in force by what nurses do.
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