In loose and general terms, a moral dilemma is what happens when someone is caught between two (or more) conflicting legitimate moral claims.
A resolvable moral dilemma, on the one hand, is one in which one moral claim on the agent in question is more important than the other. In such a case, the agent is in the position of having to choose between a greater and a lesser evil.
An irresolvable a moral dilemma, on the other hand, occurs when someone has to make a decision between two (or more) options, where morality gives absolutely no guidance regarding which decision to make.
I find moral dilemmas utterly fascinating, and one came up in class last week. We were talking about professionalism in nursing, and this case was never resolved in class (to my satisfaction, at least).
As a nurse, there are certain obligations that arise just by virtue of the fact that a nurse is a professional. For example, a nurse is bound by confidentiality, just because she is a nurse. (And not necessarily because she offers a promise of confidentiality to any particular client.) It would be severely unprofessional for a nurse to disclose the physical condition of one of her clients to someone who is not directly involved in the client’s care.
Conversely, a nurse sometimes has a duty to share certain pieces of information regardless of the wishes of the client for the information to be kept confidential, and this duty arises just because she is a nurse.
It’s really easy to see how these two professional obligations in particular could result in incompatible but legitimate moral claims on a nurse’s conduct. There are some examples where it’s clear what a nurse should do, but then there are a lot of cases where it’s not so clear. I’ll lay out a number of such examples to illustrate.
The child molester
In this case, a client is sexually molesting his nine-year-old niece, and he tells the nurse, but asks her to keep it a secret. Here, it is clear that regardless of the wishes of the client to keep his conduct secret, the nurse has a professional obligation to tell certain people (the niece’s parents, the police) about the molestation because of the degree of harm to the niece. I think it is non-controversial that we could characterise this as a classic resolvable dilemma—the nurse should break confidentiality, which is a legitimate moral constraint on her actions, but because the nurse also acts to prevent harm to the patient, she chooses the lesser evil.
This case is clear. The wrong of breaking confidentiality is clearly outweighed by preventing the wrong of further sexual exploitation. But what about cases that are otherwise parallel, but in which there is less harm to the child? Here’s a few other cases with decreasing harm to the niece.
The enabler
In this case, a client is saving his pain medication and giving it to his nine-year-old niece because she likes the way it makes her feel. He tells the nurse, in full expectation of confidentiality.
Cigarettes
Here, the client reveals that he is buying cigarettes and giving them to his nine-year-old niece. He has not told the niece’s parents, and indicates that he wants the nurse to keep this quiet.
Alcohol
A client says that he is buying beer for his niece. The parents don’t know, and he indicates that he expects the nurse to respect confidentiality in this matter.
Lots of candy
This is the same situation as the previous, but instead of alcohol, the client is giving his niece an unhealthy amount of candy.
Bad TV shows
This is the same situation as the previous, but instead of candy, the worst thing that the client does that has an impact on his niece’s health is that sometimes he lets his niece watch cartoons on the television. He doesn’t want the nurse to tell his sister (the niece’s mother) because he is a somewhat insecure man and he is afraid that if his sister found out that he and his niece were bonding over Looney Tunes, he would be teased.
In the last case, Bad TV shows, I think most people would say that the nurse should respect the client’s wish to keep the matter secret, since the harm to the child is minimal. That is, if a nurse spoke to the niece’s parents, it might even be seen as an unprofessional breach of trust.
So at either extreme, it is very clear what the nurse should do. In The child molester, we think the nurse ought to say something and break confidence. In Bad TV shows, we think the nurse really doesn’t have good enough reason to break confidentiality. It’s the cases in between where there is some uncertainty. Where do we draw the line?
Probably The enabler is a case where confidence should be broken. To be honest, I’m not sure about Alcohol.
Here’s another consideration: for some moral dilemmas moral philosophers will say that they are only resolvable “with remainder.” That is, even if the moral agent correctly identifies and takes the horn of the dilemma that is the lesser evil, the option that is not taken still retains some of its moral force, and requires something on the part of the moral agent to resolve it, like remorse, regret or apology.
In a case like The child molester, if the nurse breaks confidentiality to tell the parents and the police about the exploitation, most people won’t think that anything (like an apology) is owed to the molester. In the less extreme cases, this becomes less clear, I think, and especially if we don’t make the assumption that the client in question is doing something that she knows to be wrong.
I don’t have answers to the questions here. I’m not even sure if this “balancing” of interests is the best way to conceive of the problem.
The “correct” answer that we were given in class is that before the client offers us a secret, we should disclose to the client that, depending on what the secret is, we might have to tell someone. The problem with that answer is that a nurse does not just come by incompatible moral obligations by virtue of poorly thought-through promises she makes. Confidentiality and concern for the well-being of others are obligations that bear on nurses regardless of whether they say that they will keep a secret or not, and so a more fine-grained and nuanced approach to this problem is needed.
