The good, the bad and the 'not so bad': reflecting on moral appraisal in practice.

The aim of this study is to facilitate reflection on the moral merit of practitioners in various contexts. Insight is gained from Aristotelian and Kantian accounts of moral character and an original framework for reflection is presented as an adjunct to ethical theory and principles considered when appraising others. In relation to states of character, there is an irreconcilable difference between Kantian (deontic) and Aristotelian (aretaic) conceptions of the nature of full virtue (excellence of character), but at the same time it can be argued that in relation to practice their approaches complement each other. It is also argued that in relation to caring for the vulnerable, Aristotle's conception of full virtue is more compelling than Kant's. On the other hand, Kant's notion of self-serving action is important in nursing and it therefore needs to be considered when reflecting on professional conduct. The conclusion reached is that Aristotelian and Kantian accounts of character appraisal should be used in a combined approach to moral appraisal. This approach draws on the accounts of both philosophers and offers valuable insight into moral character, professional conduct and, in a more formal setting, fitness to practise.

Tolstoy, stories, and facilitating insight in end of life care: exploring ethics through vicarious experience.

Facilitating moral insight in end of life care can be challenging, and the purpose of this paper is to illustrate how this can be nurtured by means of creative literature. Tolstoy's Death of Ivan Ilych is presented as an example of such literature. Aristotle's Nichomean Ethics provides the philosophical underpinning for the method used. Sources also include the nursing literature, and students' evaluations of the impact of Tolstoy's novella on their ability to perceive the ethical issues arising in end of life care. Comments from evaluations were analysed and significant themes emerged. Students' comments clearly support the suggestion that use of this novella has facilitated insight into ethical issues at the end of life. Evaluations also indicate that vicarious experience gained through reading this novella has helped to nurture sensitivity and professional insight into the importance of compassion and offering 'comfort' to the dying person.

Cricoid pressure: a review of the literature.

Aspiration pneumonitis (Mendelson's syndrome) is universally accepted as a complication of general anaesthesia. According to Ellis et al (2007) death from aspiration was first described by Simpson in 1848, and it was not until 1946 that Mendelson identified acid aspiration in a significant number of obstetric patients undergoing facemask anaesthesia. The advent of techniques to secure the airway, through the use of airway adjuncts has gone some way to reduce the likely incidence of aspiration in today's perioperative arena. The positive outcome for patients is corroborated by Neilipovitz & Crosby (2007) who report aspiration as a rare complication with an overall incidence of 1:2,000-3,000. As Ewart (2007) highlights, Mendelson's syndrome is due to pharmacological effects at a molecular level which occur in the airway tissues and are caused by the use of induction and neuromuscular blocking agents. The resultant loss of consciousness and consequent diminished protective airway reflexes ultimately places the patient at risk until their airway is secured. Preventative measures to protect the lung from contamination with gastric contents, for example preoperative fasting, are therefore instigated prior to securing the airway.

Guilty but good: defending voluntary active euthanasia from a virtue perspective.

This article is presented as a defence of voluntary active euthanasia from a virtue perspective and it is written with the objective of generating debate and challenging the assumption that killing is necessarily vicious in all circumstances. Practitioners are often torn between acting from virtue and acting from duty. In the case presented the physician was governed by compassion and this illustrates how good people may have the courage to sacrifice their own security in the interests of virtue. The doctor's action created huge tensions for the nurse, who was governed by the code of conduct and relevant laws. Appraising active euthanasia from a virtue perspective can offer a more compassionate approach to the predicament of practitioners and clients. The tensions arising from the virtue versus rules debate generates irreconcilable difficulties for nurses. A shift towards virtue would help to resolve this problem and support the call for a change in the law. The controversial nature of this position is acknowledged. The argument is put forward on the understanding that many practitioners will not agree with the conclusions reached.

Practising virtue: a challenge to the view that a virtue centred approach to ethics lacks practical content.

A virtue centred approach to ethics has been criticized for being vague owing to the nature of its central concept, the paradigm person. From the perspective of the practitioner the most damaging charge is that virtue ethics fails to be action guiding and, in addition to this, it does not offer any means of act appraisal. These criticisms leave virtue ethics in a weak position vis-à-vis traditional approaches to ethics. The criticism is, however, challenged by Hursthouse in her analysis of the accounts of right action offered by deontology, utilitarianism and virtue ethics. It is possible to defend the action guiding nature of virtue ethics: there are virtue rules and exemplars to guide action. Insights from Aristotle's practical approach to ethics are considered alongside Hursthouse's analysis and it is suggested that virtue ethics is also capable of facilitating action appraisal. It is at the same time acknowledged that approaches to virtue ethics vary widely and that the challenges offered here would be rejected by those who embrace a radical replacement virtue approach.