1. Aspects of complex confrontation between the justice and care perspectives
In this study, the moral conflict observed from the perspective of justice and care showed conflicting aspects, while the two perspectives themselves are intricately intertwined due to the fact that each perspective supports conflicting actions and a single perspective can support conflicting actions, and these overlaps complicated the moral conflict.
1.1 Supporting contradictory actions from each justice and care perspective
Because the justice and care perspectives are contradictory in nature, each perspective may support conflicting actions. In this study, among the many cases that included a conflict between the two perspectives, “rules” of the justice perspective and “welfare of others” of the care perspective frequently occurred in each perspective. These categories were considered to be key concepts within the nurses’ justice and care perspectives. Therefore, we will consider the causes of conflict and their solutions centering on two categories.
1.1.1 Conflict between “rules” and “welfare of others”
This conflict was attributed to be organizational constraints influencing patient care. In this study, “rules” and “welfare of others” were in conflict with each other and showed distinctive characteristic of the conflict between the justice and care perspectives (C2-4, 6, 9, 10, 13,16). The nurses in this study were concerned with meeting specific patient and family needs while adhering to organization-specific rules. Indeed, best nursing practice for patients and families tends to be hampered by organizational constraints [30–33]. Organizational structures have aspects that affect nurse workload, especially staff shortages, high patient turnover, and administrative tasks that cause excessive workload and difficulty in providing adequate patient care [30]. Healthcare facilities require certain organizational constraints to distribute healthcare resource equally to those in need while ensuring the safety of those within the institution. Since these constraints do not consider the involvement of individual patients or specific situations, conflicts arising from constraints imposed by organizational rules are fundamentally difficult to resolve. However, if organizational factors continue to make the situation undesirable for the patient, the situation may be normalized and the staff may be justified in their actions [34, 35]. Additionally, care staff may omit time-consuming care, citing staff shortage or heavy workloads as an excuse [34, 35]. Such situations should not be overlooked, and organizations have a responsibility to remove and improve barriers to desirable practice for patients [33] and should take steps to lead to conflict mitigations. As one of them, it is suggested to appropriately adjust the staffing according to the workload. Indeed, staffing shortages are caused by sudden events such as rapid deterioration of the clinical condition of patients or an increase in the number of critically ill patients, resulting in an excessive workload [36]. Such workload and staffing mismatches are associated with poor quality of care as well as adverse outcomes of patients [37, 38]. Staffing needs to be adjusted according to workload to enable the provision of care according to individual patient needs, which may be one of the conflict mitigation measures.
1.1.2 Conflict between “welfare of others” and “roles”
“Welfare of others” of care was often in conflict with “roles” of justice (C1, 7 ,8, 9, 18, 19). This conflict was attributed to nurses' lack of authority over clinical decision-making. In this study, much of that authority lay with physicians, team leaders, and nurse managers; nurses were forced to choose between following the decisions of those in authority or advocating for the best interests of individual patients. Nurses tend not to be involved in treatment and care decisions making because of lack of authority of nurses and, as a result, do not act for the ethically desirable decisions for patients [27, 31]. Even if such nurses attempt to be involved in ethical decision-making, they either give up on their involvement because of their experience of getting negative results from moral acts, or justified their non-involvement because of the lack of benefit that their involvement would bring [34]. Such a situation violates the principle of beneficence and nonmaleficence of the healthcare professional. Since nurses have different professional roles and duties from physicians and managers, it is difficult to fundamentally resolve this conflict. As one of the measures to mitigate conflict, it is suggested to improve communication within the medical professional team and to develop nurses' participation in clinical decision-making. Because physicians have to shoulder more legal or professional liability, much of the authority in healthcare falls under their jurisdiction [39]. This has led to an entrenched idea among nonphysician clinicians that they act on the basis of hierarchical leadership of physicians, which sometimes makes their collaborative approach to leadership difficult [39]. Communication failure within the interprofessional team is more than just a failure of transfer information and lack of shared understanding; it can lead to delayed in care, medical errors, and poor outcome of patients [40–42]. Additionally, nurses need financial and emotional support from their organizations to participate in patient-related decisions [33]. They motivate nurses to act ethically, leading to the provision of quality care to patients.
1.1.3 Conflict between “welfare of others” and “rights”
In this study, “welfare of others” of care was also often in conflict with “rights” of justice (C5, 6, 11, 15, 17). This conflict was attributed to be the inability of patients with reduced decision-making ability to make decisions about their own well-being. While the nurses in this study believed that recovery of health and sustaining life through treatment would bring welfare to patients and their families, since the treatment was performed without the patient's consent and was painful, nurses believed that it was necessary to make decisions on the basis of the patient's will.
Rights are an important concept in the ethics of justice; however, in medical settings, respecting the patient’s rights is not always considered to lead to patient well-being. For example, in life-threatening emergencies, many patients have reduced decision-making capacity, and liberty-restricting measures such as physical restraint and coercive treatment are sometimes prioritized [43]. In such cases, the application of shared decision-making (SDM) is common; however, the choice of SDM surrogate does not always match the patient's true wishes [44, 45]. Especially, it is recommended that dementia and terminally ill patients express their values and preferences in advance directives to prepare for future disability [46]. However, even with a patient's advance directive in practice, healthcare professionals do not consistently respect it [47–49], and in immediate and reversible situations, the clinician's decision making may prevail depending on the patient status [48].
As explained above, if patients have difficulty self-determining or implementing SDM, paternalistic interventions are tolerated in lights of beneficence and nonmaleficence within the ethics of care [50, 51]. Paternalism is interpreted as benevolent decision-making in others’ best interests, and therefore, justified for the interests and well-being of the patients forced into treatment and care [52, 53]. However, interventions based on paternalism must be implemented carefully as they have various effects on patients. Ptients who get coercive treatment may recall such treatment as a negative or positive experience, affecting their quality of life after discharge [43]. Negative recollections lead to a loss of autonomy and dignity of patients, while positive recollections lead patients to appreciate the benefit of the care and acknowledged being treated with respect [43]. Therefore, for recognizing the impact of paternalistic interventions on patients, it is necessary for nurses to exercise paternalism carefully and treat patients with respect.
1.2 Supporting actions in which a single perspective conflict with itself
In this study, the sometimes self-contradictory nature of the justice and care perspectives complicated not only the conflict between the justice and care perspectives but also the moral conflict.
1.2.1 Supporting contradictory actions from justice perspectives
The conflict between moral categories of the justice perspective in this study mainly included the categories of “rules,” “rights,” and “roles” (C5-7, 9–13, 22–24). This conflict was attributed to be dual loyalty. In nurse responses, “rules” indicated organization-specific rules, “roles” indicated professional roles and lack of authority, and “rights” indicated respect for patient self-determination and will. Nurses often had to balance the different interests of patients and their family members or professional duties to a patient and obligations to the interests of a third party [54]. In medical settings, fidelity to patients may conflict with allegiance to colleagues, organizations, or the nation, and two or more roles and associated loyalties and their obligations become incompatible, forcing a moral choice between them [55]. Principles based on the justice perspective in the actual moral conflicts of nurses are the roles and powers inherent in the profession, the rules within the organization, and since they are both professionals and employees, simply choosing one is difficult.
1.2.2 Supporting contradictory actions from care perspectives
In this study, conflicts between moral categories of the care perspective included “welfare of others” category. This meant that consideration of well-being according to the needs of patients and their families was essential in nurses' moral conflicts. The “welfare of others” category often conflicted with “appreciation of differences;” disagreements arose among medical professionals and families about the best care of the patient (C7, 18, 19, 20, 21, 25). This conflict was attributed to differences between caregiver responsibilities. Toronto lists four phases of care – caring about, taking care of, care-giving, and care-receiving – and stated that there is likely to be conflict within each of the phases, and between them [5]. Caregivers often find that many people have their own responsibilities that conflict with each other [5]. In medical settings, those who make up the relationship with the patient are the patient's family, nurses, and other healthcare professionals, all of whom have different responsibilities in their respective positions. Indeed, in medical settings, family members and medical professionals may make different judgments about the needs of patients, and professionals often have a different opinion [56, 57]. In such a situation, if nurses only recognize the responsibilities of patients, families, and other healthcare professionals, it will be difficult to resolve conflicts, and it will be difficult to make a choice between the various needs that each person perceives.
In addition, in this study, the “welfare of others” category often conflicted with the categories of “not hurting” and “care of self” (C5, 15, 16, 17). Conflicts also arose from contradictory considerations within the “welfare of others” category itself (C6, 16, 25). In particular, in the conflict between “welfare of others” and “care of self” categories, nurses felt guilty to the patient's suffering due to treatment and procedure. These factors were considered to be due to the multifaceted needs of patients. Nurses are expected to provide holistic support to the patients, but in reality, they sometimes dither over whether to respond to the patient's physical needs or psychological needs [58]. Healthcare professionals' prioritization of patient needs in medical settings varies according to the patient's clinical status and tends to focus on biomedical aspects. Especially in emergency and acute care settings, a dominant biomedical focus by nurses has been identified, with nurses prioritizing the completion of physical care tasks over patients’ psychosocial needs [59, 60]. Among them, nurses' distress increases when a patient is perceived to be suffering or when relationships between caregivers and distraught family are breaking down [61]. Therefore, nurses feel morally distressed when they are unable to act as advocates for patients and families [62], may be lack of compassion for patients' suffering, or cause burnout [58, 63]. Patients need to be provided with humanized care, that is, holistic care [64], and it is difficult to prioritize only one aspect of patient needs.
2. Significance of the coexistence of justice and care in individuals
2.1 The relationship between the justice and care perspective-taking and ego development
In this study, most nurses considered their options of action using both justice and care perspectives. The perspective of justice and care is one that everyone has regardless of their occupation [65]. According to the view in moral psychology research, ego development is related to the moral reasoning development [66]. Care-based and justice-based reasoning have developmental paths of their own [67]. Care and justice reasoning progress from self-interest concern toward others’ concern by growing capacity to adopt others’ viewpoint, and it may share elements in ego development such as cognitive style, impulse control, and character development [68, 66]. In Juujärvi 's study, care reasoning was positively related to justice reasoning, suggesting that justice and care complement each other in sophisticated moral reasoning [68]. Therefore, it can be considered that individuals acquire the moral perspective of both justice and care as they achieve moral development along with the ego development.
2.2 Justice and care in professional ethics
The ethics of justice and care are applicable to ethical decision-making in medical settings and play an important role in healthcare workers’ professional ethics [20, 69, 19]. The code of ethics for nurses explicates respect for human rights, self-determination, and equitable treatment of patients, regardless of their background in accordance with an ethic of justice; it also explicates responsibility to meet patient needs in accordance with an ethic of care [67, 23]. In addition, Green, premised on engendering future humane physician-patient relationship in the future, cites ethics of care as a model for the physician-student relationship in medical education [70]. Indeed, those aspiring for interpersonal care professions such as healthcare and social work make higher quality reasoning from a care perspective than those in other fields (security and business management) [68]. A previous study of physicians, nurses, and medical students found that most people perceive both justice and care in moral conflicts, and some make decisions that combine both perspectives [9, 71, 65, 72]. In particular, responding to the needs of dependent and helpless people is a professional commitment to care for others [73]. Together, the justice and care perspectives provide a rationale for action in terms of providing equitable healthcare to every patient and responding to patient needs.
2.3 Influence on decision-making from single perspective
Perspectives of justice and care coexist in individuals; however, in some cases only one perspective supports two opposing actions. Thus, distortions can occur when a person's moral orientation is biased toward either justice or care [74]. First, a moral orientation that only considers the perspective of justice may overlook the needs of patients. The individualistic focus of the ethics of justice leads to an excessively respect of autonomy, ignoring the social conditions necessary for self-determination [74]. In other words, viewing human beings as rational, autonomous individuals, even if they have vulnerabilities and dependencies, leads to a lack of focus on the needs of those who need support [67]. In this study, nurses with only the perspective of justice encountered multiple conflicts based on their professional responsibilities and did not focus on the needs of specific patients (C22-24, Table 2). Justice-oriented or justice-predominant nurses tend to be task-focused based on roles, rules, and obligations. In fact, the lack of equipment and time-scarce environment due to patient overcrowding in emergency settings caused a loss of dignity for patients requiring specific care, such as terminally ill patients [75]. Real moral conflicts can be observed in patient-specific contexts, and it is not always best evaluated ignoring them and weighing professional obligations.
Focusing only on the perspective of care carries the risk of overlooking the value of autonomy [74]. The relationship between the caregiver and the care-receiver facilitates the creation of power relationship and risks suppressing the care-receiver's desires and thoughts [76]. Patients have senses of dignity and desire to control their lives based on autonomy [77]. In this study, nurses with a care-only perspective focused on the complexity of relationships with the healthcare staff and families and did not focus on patients' desire (C25, 28, 29, Table 2). Failure to consider the patient's perspective in the relationship between the caregiver and the care receiver is contrary to the essence of ethics of care [76]. Such situations lead to disrespect for patient autonomy and risk giving rise to strong paternalism that places caregivers in strong positions.
3. Possibility of conflict resolution
3.1 Argument from the perspectives of justice and care
To resolve conflicts that are complexly intertwined between perspectives of justice and care, our research suggests the necessity of discussion from both perspectives. Biased discussion from one perspective causes unfavorable distortion. To prevent important oversights in considering ethical issues, discussing them from the perspectives of both justice and care is crucial. Recognizing that justice and care are heterogeneous, care theorists have debated the compatibility of justice and care ethics [3, 74]. Recently, discussing ethics of care has become important when considering ethical issues [12, 13, 78, 72]. The use of ethics of care helps identify and detail the serious ethical issues through the interpretation of contextual aspects [78]. Therefore, the ethics of care should be used to resolve complex conflicts involving perspectives of justice and care.
3.2 Necessity to propose practical measures
Moral conflicts, in which perspectives of justice and care are intricately intertwined in this research, tended to be difficult to resolve for those who encountered them. In this context, nurses tend to behave in conventional patterns of ethical reasoning and practice that follow convention, such as rules and standards of the society, rather than pursuing patient well-being [79, 27]. In this study, it was considered difficult to fundamentally resolve the conflict between justice and care caused by organizational constraints and the lack of role authority of nurses. However, measures to mitigate conflict in individual situations are necessary. As an example, we listed the appropriate personnel allocation and the maintenance of the nurse participation system. Improving the organizational environment, such as making rules related to personnel shortages more functional and enabling active discussions within interdisciplinary teams, will help alleviate conflicts. Therefore, it is important to formulate measures to minimize conflicts between the justice and care perspectives as much as possible.
Limitations
A weakness of this study is sample bias. Since this research is a survey targeting only Japanese nurses, it is an analysis limited to the medical system and medical practice of the country. As such, the moral conflicts obtained in this study may differ from those in other countries. In this respect, the generalizability of the results of this study is limited.
In addition, since this research used a deductive method using Chally's taxonomy of justice and care, it resulted in the extraction of complex conflicts in which conflicts between perspectives of justice and care and within a single perspective coexist. If we use an inductive approach, the results may have found more essential issues about moral conflict.