INSTRUCTIONSCompose an outline that answers this question: How is Virtue Theory related to medical practice? Use two pieces of information from this week’s material to support your points. Follow outline structure in example provided, including spacingInclude cover page and reference pageCite at least two pieces of information from the week’s material according to APA guidelinesOutline itself must be at least one full pageEach paper is limited to no more than a 30% for the originality report. Papers that exceed this limit will have significant point deductions.NOTE: Before submitting your paper, use the interactive APA Formatting Checklist to make sure that you meet all of the APA Style requirements for this assignment.Answer the questions honestly, and you will be directed to resources to help you complete this aspect of the assignment.Vicki D. Lachman
Troublemakers or Virtuous Nurses?
egrettably, whistleblowing is still necessary in
today’s health care environment — one that is
weighed down with fraud, incompetent practitioners,
and patient safety issues. It is an action seen in movies
and heard about in organizations, yet distant from
nursing. Nurses are left with a question, “Could I stand
up for what is right like that courageous person?” The
focus of this article is to provide ethical justifications
for the action of whistleblowing as well as information
on legal protections and ways to reduce the risks and
negative consequences often experienced by the
ization to address accountability for the safety and
welfare of the patients. The nurse feels compelled in
the face of inaction to take a stand against the wrongdoing in the organization. Because staff nurses have
an increasing responsibility to maintain an ethical
practice environment, it is important to cover the
organizational ethics issues and solutions as well. A
discussion of what both the organization and the
nurses in leadership roles within the organization can
do to help maintain the business’ moral compass will
be discussed in an upcoming Ethics, Law, & Policy column.
What Is Whistleblowing?
When Is Whistleblowing Morally Required?
Whistleblowing is an attempt by a member or former member of an organization to issue a warning to
the public about a serious wrongdoing or danger created or concealed by the organization (Ahern &
McDonald, 2002; Bolsin, Faunce, & Oakley, 2005; Davis
& Konishi, 2007). Numerous definitions of whistleblowing appear in health care and business literature,
but all point to the importance of advocacy, that is,
protecting someone who will likely be harmed. For
this article, the definition will differentiate between
reporting the problem within the organization and
whistleblowing to an external agency (Fletcher,
Sorrell, & Silva, 1998; Sellin, 1995).
To define the terms further within the scope of
nursing, whistleblowing is the action taken by a nurse
who goes outside the organization for the public’s
best interest when it is unresponsive to reporting the
danger through the organization’s proper channels.
Reporting is the action taken by the nurse inside the
channels of his or her organization to correct a dangerous situation. Examples of reporting include incident reports and verbal reporting to line managers
(Firtko & Jackson, 2005).
These definitions indicate that whistleblowing results from a failure of the ethical climate of the organ-
The ethical theories used in this article to justify
whistleblowing are Kantian (duty), virtue, and utilitarian (Bolsin et al., 2005; Grant, 2002; Kline, 2006).
Kantian theory instructs people to act in harmony
with universally accepted rules. Telling the truth is at
the heart of this deontological theory (Kant, 1996).
Though Kant had no way of knowing the self-sacrifice
that is often required in whistleblowing, I believe that
Kant would want an individual to stand firm in telling
the truth, regardless of personal outcome.
Virtue theory requires an individual to personify
integrity and courage (Adams, 2006; Bolsin et al.,
2005). Reporting unethical colleagues, patient safety
violations, or health care fraud requires the integrity
found in professional character. For example, a primary goal is to remain loyal to providing relief to a
patient in suffering. Turning a blind eye to practices
that go against that primary aim would not only
breach the nursing Code of Ethics (duty) (American
Nurses Association [ANA], 2001), but it would also
violate the basic virtues of honesty and courage.
The ethical theory of consequentialism (utilitarian) provides a powerful justification for whistleblowing: maximizing the human benefit and minimizing the
harm. Below is the standards theory summarized by
Davis (2003, pp. 89-90) and describing when whistleblowing is morally required for the greatest good of
➤ The organization to which the would-be whistleblower belongs will, through its product or policy,
do serious considerable harm to the public
Vicki D. Lachman, PhD, MBE, APRN, is a Clinical
Associate Professor, Drexel University, Philadelphia,
MEDSURG Nursing—April 2008—Vol. 17/No. 2
(whether to users of its product, to innocent bystanders, or to the public at large).
➤ The would-be whistleblower has identified that
threat of harm, reported it to the immediate supervisor, making clear both the threat itself and the
objection to it, and concluded that the superior
will do nothing effective.
➤ The would-be whistleblower has exhausted other
internal procedures within the organization (for
example, by going up the organizational ladder as
far as allowed), or at least make use of as many
internal procedures as the danger to others and
his or her own safety make reasonable.
➤ The would-be whistleblower has (or has accessible) evidence that would convince a reasonable,
impartial observer that his or her view of the
threat is correct.
➤ The would-be whistleblower has good reason to
believe that revealing the threat will (probably)
prevent the harm at reasonable cost (all things
Sometimes the threat to the safety or health of
patients is so immediate that going through the channels of a hierarchical structure could cost patients’
lives. If the immediate supervisor is the source of the
problem, the nurse has no choice but to leap up a level
above him or her in the organization. Unfortunately,
not following the chain of command could be the
resulting focus of the retaliation rather than the identified ethical issue. If blindness to the danger extends to
the next level in the hierarchy, the individual’s loyalty
to the organization or his or her naiveté on how a
health care organization functions could become the
issue. This is because whistleblowing challenges the
amoral view of the organization; from the organization’s point of view, the nurse was unable to resolve
the ethical concerns internally (Grant, 2002).
Who Are Whistleblowers?
Whistleblowers are generally seen as brave individuals who take a stand against the practices of an
organization. Whether in business or health care, the
cases are similar to the examinations of 64 whistleblowers by Glazer and Glazer (1989). They are parallel
to the movie The Insider, which depicted the tactics of
the tobacco industry to hide the addictiveness of its
product. Many stories indicate that whistleblowers
face adversity when standing up to an organization,
including that of Barry Adams, RN (Fletcher et al.,
Barry Adams worked in a sub-acute unit in a New
England hospital in 1996. As the hospital implemented
staffing cuts and cost-containment actions, he became
increasingly distressed about the quality and safety of
the patient care. His careful documentation revealed
that inadequate staffing and lack of supervision of new
staff correlated not only with patient falls, but also
with incomplete treatments and serious medication
errors. For 3 months, Mr. Adams documented and
communicated his concerns up the chain of command
within the hospital. He was fired eventually for his
actions. He sued the health care organization and won;
MEDSURG Nursing—April 2008—Vol. 17/No. 2
upon appeal, the hospital lost a second time. For Mr.
Adams, like most other whistleblowers, personal and
professional reputation was above reproach.
Iliffe (2002) identified whistleblowing as an obligatory rather than a chosen state. From that point of
view, whistleblowers find themselves in a position
either to speak out or to remain silent. At those
moments, the situation and the virtue of courage collide. Some nurses choose to maintain standards they
have as personal and/or professional. Like Barry
Adams, they are often not average performers. They
are above-average performers committed to the organization with a strong belief in moral principles (Grant,
What Are the Negative Consequences to the
Comprehending the public character of whistleblowing is crucial to appreciating the risks associated
with the action. When whistleblowing is interpreted as
I have defined it, the action requires moral courage.
Malcontents who file frivolous lawsuits or draw attention to themselves in public media are not the focus of
this article. Those scattered individuals undermine
the courageous nurses who risk so much to honor
their Code of Ethics and alert someone to wrongdoing
and neglect within a health care organization. In the
case of Barry Adams, 21 individuals came forward in
the suit to attest to his integrity and protest his termination (Fletcher et al,, 1998).
The list of negative consequences to whistleblowing seems endless: broken promises to fix the problem, disillusionment, isolation, humiliation, formation
of an “anti-you” group, loss of job, questioning of the
whistleblower’s mental health, vindictive tactics to
make the individual’s work more difficult and/or
insignificant, assassination of character, formal reprimand, and difficult court proceedings (Ahern &
McDonald, 2002; Brodie, 1998; Fletcher et al., 1998;
Wilmot, 2000). As Barry Adams learned, blowing the
whistle can be a life-altering incident. Even though Mr.
Adams lost his job, he must have felt a sense of
achievement for speaking out about patient safety
What Legislation Provides Support to Whistleblower?
Under the 1st and 14th Amendments to the U.S.
Constitution, state and local government officials are
prohibited from retaliating against whistleblowers
(Faunce, 2007). Federal regulations offer legislative
protection for reasonable allegations of whistleblowers who acted in good faith for public interest because
of a substantial and imminent threat to public good.
Additionally, more than two-thirds of U.S. states have
passed legislation to protect whistleblowers from
retaliation (Grant, 2002). However, who is covered,
what is covered, and how and when individuals are to
report incidents vary from state to state (Drew &
Garrahan, 2005). A person would be wise to know his
or her rights and the procedures required before
deciding to blow the whistle on an organization.
Two Web sites provide information, books, blogs,
A Guide for Moral Decision Making
What are the moral dimension(s)?
Who are the interested parties? What are their
What values are involved?
What are the benefits and burdens that need to be
Are there any analogous cases?
Who are relevant others with whom you could discuss
Does the decision accord with legal and organizational
Am I comfortable with the decision?
Source: MacDonald, 2002.
Internet links, and other guidance. The National
Whistleblower Center is a nonprofit, tax-exempt, educational and advocacy organization dedicated to helping
Since 1988, this organization has used whistleblowers’
disclosures to improve government and corporate
accountability, environmental protection, and nuclear
safety. Though not specifically focused on health care,
the center’s Web site provides a wealth of information.
The second Web site, Freedom to Care, does have a
health care component. However, it is focused on issues
in Great Britain (http://www.freedomtocare.org/). A link
on this Web site connects nurses and nursing students to
the International Association for Nursing Ethics and
information on the ethical issues involved in whistleblowing (http://www.freedomtocare.org/contents.htm#
The False Claims Amendment Act of 1986 primarily
focused on prohibiting any false claim for reimbursement
to the United States, but it did include a whistleblower provision (qui tam) (http://www.taf.org/whyfca.htm). This
regulation protects whistleblowers who disclose violations that involve fraudulent use of federal funds. The
whistleblower can be a current or former employee, a
patient, a competitor, or any person who obtains firsthand knowledge of fraudulent behavior. This person
can file suit on behalf of an entity and recover 15%-30%
of any settlement. If the government wins the case, then
the whistleblower could win a substantial amount of
money. For example, in fiscal year 2006, the U.S. government recovered a record $3.1 billion in cases of fraud
(DoBias, 2007). Tenet Healthcare Corp’s $920 million
settlement accounted for the largest percentage of the
$2.2 billion from recoveries in health care.
Is There a Moral Guide to Solve the Whistleblower Dilemma?
If effective and well-communicated internal structures are available to ensure employees’ concerns are
addressed, the need for whistleblowing does not exist.
However, in a less than idealistic world, the nurse
needs a model on how and when to voice a concern
that helps reduce the risk as much as is feasible.
MacDonald (2002) provided such a guide to moral
decision making. The model is outlined with slight
alteration in Table 1.
An example to exemplify this model could be the
continuous violation of an advance directive for a
patient who is in the terminal phases of illness, or who is
unconscious and therefore unable to voice his or her
choices. By choosing to remain silent, the nurse would
be complicit in violating the moral dimension of the
patient’s autonomy asserted in the advance directive.
The interested parties would include all other
health care professionals caring for the patient, the
patient’s surrogate decision maker, and the nurse managers responsible for the unit. By speaking up in such a
situation, a nurse would be in danger of undermining the
status quo of the organization and breeching loyalty to
the “conspiracy of silence,” and could be seen as a troublemaker.
The issues of values, benefits versus burdens, and
legal cases need reflection. The values espoused
through the Code of Ethics (ANA, 2001) address the
autonomy of the patient as well as the responsibility of
the surrogate to speak for the patient. The burdens on
the patient are more obvious than those on the nurse
who speaks for the patient. The preceding negative consequences (burdens) outlined for the whistleblower
may seem out of proportion to the benefits of integrity.
Barry Adams, RN, could be an analogous case (Fletcher,
1998), but so could other nurses who refused to violate
the patient’s right to self-determination. MacDonald and
Ahern (1999) found that talking to a respected friend or
relative about the dilemma is an effective way to cope
with whistleblowing. Violating the patients’ advance
directives violates not only the Code of Ethics, but other
legal and organizational rules. The Patient’s Self
Determination Act (Galambos, 1998) and policies with
the organization relative to advance directives also
would be violated.
Finally, the nurse needs to ask, “Am I comfortable
with this decision?” MacDonald (2002) offered some
questions that can help the nurse address this question.
The nurse may not be “comfortable” because often situations requiring the virtue of integrity and courage are
not comfortable at the time. However, it is imperative
that the nurse ask the following questions to determine
if, in the long term, he or she could continue in the profession while maintaining a high level of integrity.
Questions could include:
1. If I carry out this decision, would I be comfortable
telling my family about it?
2. Would I want my children to take my behavior as an
3. Is this decision one which a wise, informed, virtuous
person would make?
4. Can I live with my decision?
I believe that the ends do justify the means of
whistleblowing, when the ends are increased patient
safety, change in misconduct, and/or an ethical climate that supports professional nursing. As a professional, every nurse needs to champion whistleblowing
rather than ostracizing nurses with the moral courage
to speak out on unethical practices. Encouragement is
needed for the nurses who risk their own well-being
for the sake of the patient (Peternelj-Taylor, 2003). ■
continued on page 134
MEDSURG Nursing—April 2008—Vol. 17/No. 2
continued from page 128
American Nurses Association (ANA). (2001). Code for ethics for nurses with interpretative statements. Silver Spring, MD: American
Adams, R.M. (2006). The theory of virtue. New York: Oxford University
Ahern, K.M., & McDonald, S. (2002). The beliefs of nurses who were
involved in a whistleblowing event. Journal of Advanced Nursing,
Bolsin, S., Faunce, T., & Oakley, J. (2005). Practical virtue ethics:
Healthcare whistleblowing and portable digital technology. Journal
of Medical Ethics, 31(10), 612-618.
Brodie, P. (1998). Ethics. Whistleblowing: A moral dilemma. Plastic
Surgical Nursing, 18(1), 56-58.
Davis, A.J. & Konishi, E. (2007). Whistleblowing in Japan. Nursing
Ethics, 4(2), 194-2001.
Davis, M. (2003). Some paradoxes of whistleblowing. In W.H. Shaw
(Ed.), Ethics at work (pp. 85-99). New York: Oxford University
DoBias, M. (2007). Whistle-blower law tightened: Ruling demands firsthand knowledge of wrongdoing. Modern Healthcare, 37(14), 8.
Drew, M.G., & Garrahan, K. (2005). Whistleblower protection for nurses and other healthcare professionals. Journal of Nursing Law,
False Claims Act Legal Center, The. (n.d.). Why the False Claims Act?
Retrieved January 27, 2008, from http://www.taf.org/whyfca.htm
Faunce, T.A. (2007). Whistleblowing and scientific misconduct: Renewing legal and virtue ethics foundations. Medicine and Law,
Firtko, A.J., & Jackson, D. (2005). Do the ends justify the means? Nursing and the dilemma of whistleblowing. Australian Journal of
Advanced Nursing, 23(1), 51-57.
Fletcher, J.J., Sorrell, J.M., & Silva, M.C. (1998). Whistleblowing as a failure
of organizational ethics. The Online Journal of Issues in Nursing, 3(3).
Retrieved January 27, 2008, from http://www.nursingworld.org/Main
Freedom to Care. (n.d.). Promoting public accountability. Retrieved
January 17, 2008, from http://www.freedomtocare.org/
Galambos, C.M. (1998). Preserving end-of-life autonomy: The Patient
Self-Determination Act and the Uniform Health Care Decisions
Act. Health and Social Work, 23(4), 275-281.
Glazer, M.P., & Glazer, P.M. (1989). The whistleblowers: Exposing corruption in government and industry. New York: Basic Books.
Grant, C. (2002). Whistle blowers: Saints of secular culture. Journal of
Business Ethics, 39, 391-399.
Iliffe, J. (2002). Whistleblowing: A difficult decision. Australian Nursing
Journal, 9(7), 1.
Kant, I. (1996). Practical philosophy. Gregor, M.J. (Trans., Ed.). Cambridge, NY: Cambridge University Press.
Kline, A.D. (2006). On complicity theory. Science and Engineering
Ethics, 12(2), 257-264.
MacDonald, D. (2002). A guide to moral decision making. Retrieved
January 27, 2008, from http://www.ethicsweb.ca/guide/
McDonald, S., & Ahern, K. (1999). Whistleblowing: Effective and ineffective coping responses. Nursing Forum, 34, 5-13.
National Whistleblowers Center. (n.d.). News from the center. Retrieved
January 27, 2008, from http://www.whistleblowers.org/
Peternelj-Taylor, C. (2003). Whistleblowing and boundary violations:
Exposing a colleague in forensic milieu. Nursing Ethics, 10(5),
Sellin, S.C. (1995). Out on a limb: A qualitative study of patient advocacy in institutional nursing. Nursing Ethics, 2(1), 19-29.
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Reprinted from MEDSURG Nursing, 2008, Volume 17, Number 2, pp. 126-128,134. Reprinted with permission of the publisher,
Jannetti Publications, Inc., East Holly Avenue, Box 56, Pitman, NJ 08071-0056; Phone (856) 256-2300; FAX (856) 589-7463. (For
a sample issue of the journal, visit www.medsurgnursing.net – Learn more about the Academy of Medical-Surgical Nurses [AMSN]
MEDSURG Nursing—April 2008—Vol. 17/No. 2
Running head: WORKING TITLE: HAVASUPAI RESEARCH PLAN
Working Title: (Your Title)
(Your Name Here)
INSTRUCTOR NOTE: This outline serves as an example only. Refer to “Assignment Details” for further information. Items in parentheses are
instructional in nature.
WORKING TITLE: HAVASUPAI RESEARCH PLAN
Thesis: Research approaches to improving the health of the Havasupai People of the
Southwestern United States, have been ineffective thus far because of inadequate attention to
appropriate conventional research, culture, community inclusion, and basic ethical principles of
research. Conducting research with the Havasupai is understandably problematic, based on the
past exploitation of the tribe.
A. Background of Havasupai health includes past research.
B. Summary of changes in research approach.
1. Past research has not considered tribe values.
2. Past research has violated tribe religion.
II. Conventional research approaches needed
A. The Belmont Report (1979) has relevant applications.
1. Show respect for persons as autonomous decision-makers or deserving of
2. Maximize benefits and minimize harm through beneficence
3. Promote justice through the distribution of benefits.
B. The Code of Federal Regulations
1. Institutional Review Boards (IRBs) must include members with familiarity of
relevant issues. (46.107)
Informed consent must be obtained and include the general requirements of
informed consent (46.116).
III. Community-Based Participatory Research (CBPR) and this project raise new ethical
A. The Havasupai have good reason to be distrustful of research.
WORKING TITLE: HAVASUPAI RESEARCH PLAN
1. History of the Havasupai tribe
2. University of Arizona (Mello & Wolf, 2010)
B. Cultural conflict with specimen storage, use and disposal has arisen unexpectedly
in past research efforts. (Mello & Wolf, 2010)
IV. Ethical principles considered when doing research among the Havasupai
A. General principles can be applied to research among the Havasupai
1. Informed consent is crucial owing to past violations.
2. IRB membership should include tribal elders or members.
B. Specific operating principles must be incorporated into the structure
1. Tiered consent is the best approach to obtain consent for long term specimen
2. The IRB should include community elders.
V. Limits and Challenges for research among the Havasupai
A. Past experience with research of the Havasupai may limit number of
B. Access to specimens may be limited due to tiered consent.
C. Economically challenged community may feel coerced.
D. Language barrier with elders may inhibit active IRB membership activity.
A. To conduct research with the Havasupai, or any indigenous group, it is
important to apply guidelines from both The Belmont Report (1979) and the
Code of Federal Regulations (2009). 1. Consideration of the Havasupai’s
historical experiences is crucial to designing an effective research plan.
WORKING TITLE: HAVASUPAI RESEARCH PLAN
a. Their experience with researchers and research
b. Unique limits and challenges
2. Application of the ethical principles of research from The Belmont Report
and Code of Federal Regulations.
a. Respect for Persons (The Belmont Report, 1979)
b. Informed Consent (The Belmont Report, 1979)
c. General requirements for informed consent (Code of federal
Regulations 46.116, 2009)
B. (Restate thesis) Research approaches to improving the health of the Havasupai
People of the Southwestern United States have been ineffective thus far
because of inadequate attention to appropriate conventional research, culture,
community inclusion, and basic ethical principles of research. Conducting
research with the Havasupai is understandably problematic, based on the past
exploitation of the tribe.
WORKING TITLE: HAVASUPAI RESEARCH PLAN
The Belmont Report. (1979). Retrieved from
Human Subjects Research. Code of Federal Regulations. (45 C.F.R. 46). (2009). Retrieved
Mello, M.M., Wolf, L.E. (2010). The Havasupai Indian Tribe: Case-lessons for research
involving stored biologic samples. New England Journal of Medicine, 363(3), 204.
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