Understanding the Kohlberg Heinz Dilemma in Nursing Ethics

As nursing students, you will face many ethical dilemmas in your future practice that will challenge you to think critically about moral principles and ethical decision-making. One famous example used to explore moral reasoning in depth is the Kohlberg Heinz Dilemma.

This thought experiment was developed by the renowned psychologist Lawrence Kohlberg as part of his theory of moral development. Kohlberg’s goal was to understand how individuals from different backgrounds and life experiences reason about ethical issues and make moral judgments.

What is Kohlberg’s Theory of Moral Development?

Lawrence Kohlberg was a 20th-century psychologist who made significant contributions to the study of moral psychology and moral education. His theory of moral development describes how people progressively develop more advanced abilities to reason about ethical issues and make moral decisions.

Six distinct stages of moral reasoning

Kohlberg proposed that individuals progress sequentially through a series of six distinct stages of moral reasoning, grouped into three major levels:

  • Pre-Conventional Level
  • Conventional Level
  • Post-Conventional Level

Pre-Conventional Level

At the Pre-Conventional Level, moral reasoning is primarily based on avoiding punishment or serving one’s own interests and needs. This level consists of:

Stage 1 – Obedience and punishment orientation: At this stage, right and wrong are judged solely by the consequences determined by an authority figure. Avoiding punishment is the driving force behind moral choices.

Stage 2 – Self-interest orientation: Moral decisions are made to serve one’s own interests, with the view that everyone else is doing the same. Reciprocal arrangements and fair exchanges are acceptable.

Conventional Level

The Conventional Level represents a shift towards valuing group norms, loyalty, and social conformity as the basis for moral reasoning. It includes:

Stage 3 – Interpersonal accord and conformity: Right conduct is defined by what pleases others and gains their approval. The desire to be a “good person” in the eyes of family and peers motivates moral choices.

Stage 4 – Authority and social order maintaining orientation: At this stage, moral reasoning is shaped by a commitment to obeying laws, respecting authority, and maintaining the established social order.

Post-Conventional Level

At the highest Post-Conventional Level, moral reasoning moves beyond upholding norms or laws and towards universal ethical principles of justice, human rights, and human dignity. This level encompasses:

Stage 5 – Social contract orientation: Moral values and rules are seen as holding value because they are agreed upon by society as a whole. Ethical principles like equality and impartiality become prioritized.

Stage 6 – Universal ethical principles: This is the highest stage, where moral reasoning is guided by universal ethical principles of justice, reciprocity, equality, and respect for human dignity. These abstract principles take precedence over laws or social norms.

According to Kohlberg, individuals progress through these stages gradually over the course of their cognitive and moral development. Higher stages integrate and build upon the reasoning of lower stages. Very few individuals fully attain the highest stage of moral reasoning.

The Dilemma

To assess an individual’s level of moral development, Kohlberg utilized moral dilemmas like the famous Heinz dilemma:

The Kohlberg Heinz Dilemma presents the following scenario:
A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her, a form of radium that a druggist in the same town had recently discovered. The druggist was charging $2,000, ten times what the drug cost him to make. Heinz, the sick woman’s husband, went to everyone he knew to borrow the money, but he could only get together about $1,000, which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said, “No, I discovered the drug and I’m going to make money from it.” So Heinz got desperate and broke into the store to steal the drug for his wife.

This dilemma poses a conflict between the moral values of protecting life (beneficence), obeying the law (non-maleficence), and respecting personal property rights (justice). How one reasons through and resolves this dilemma can reveal their stage of moral development.

Kohlberg’s Theory of Moral Development in Nursing

Studying Kohlberg’s theory and the Heinz dilemma is highly relevant for nursing education and ethical training. As nurses, you will frequently encounter ethical issues involving competing principles, conflicting perspectives, and high-stakes situations with life-or-death consequences.

Developing advanced ethical reasoning abilities is crucial for:

1) Identifying and analyzing the ethical dimensions of clinical situations
2) Applying moral principles and ethical frameworks
3) Advocating for ethical practices aligned with nursing values
4) Resolving ethical dilemmas through sound moral judgment

By understanding the stages of moral development, nursing students can enhance their self-awareness about their own level of moral reasoning. This insight enables you to critically examine your underlying rationales and motivations when making ethical choices.

It also aids in recognizing that patients, colleagues, and others involved in ethical dilemmas may be reasoning from very different moral mindsets based on their level of development. A patient prioritizing self-preservation may be operating from the Pre-conventional self-interest stage, while a colleague rigidly following institutional policies could be at the Conventional authority-obeying stage.

As nurses, the goal is to develop Post-Conventional level moral reasoning – the ability to impartially consider ethical principles like autonomy, beneficence, non-maleficence, and justice, while upholding core human values. This highest stage of moral development enables the nuanced navigation of complex ethical issues in healthcare.

By studying the Heinz dilemma through a Kohblergian lens, nursing students gain valuable practice analyzing moral reasoning from multiple vantage points. They can systematically evaluate the various ethical justifications a person could provide at each stage of development, such as:

“Heinz should steal the drug because he’ll go to jail if he doesn’t get it” (Obedience – Stage 1)
“He should steal it to help himself and his wife” (Self-Interest – Stage 2)

“A good husband should do anything to help his wife, including stealing” (Interpersonal – Stage 3)
“Stealing is illegal, so he shouldn’t have done it” (Authority – Stage 4)

“While illegal, stealing to save a life is ethical under moral philosophies of utilitarianism” (Social Contract – Stage 5)
“Heinz’s actions are justifiable based on principles of human dignity and the right to life” (Universal – Stage 6)

Analyzing the dilemma from all these perspectives cultivates ethical sensitivity, moral imagination, and the ability to see ethical issues through multiple lenses. This is invaluable preparation for the morally complex realities of nursing practice.

Kohlberg’s Stages in Practice Examples

To illustrate how Kohlberg’s theory manifests in nursing, here are some example situations and rationales representing each level:

A nurse taking medication home for personal use (Self-Interest)
“I’ve worked so hard, I deserve to take some for myself.”

Not admitting a harmful medication error (Interpersonal Conformity)
“My colleagues will be so disappointed if they find out.”

A nurse advocating for a patient’s right to refuse treatment (Universal Principles)
“While I advise against it, Mr. Jones has the autonomy to make this decision under ethical principles of informed consent.”

As you can see, applying Kohlberg’s stages reveals the underlying moral motivations driving actions, which can profoundly impact patient care and ethical decision-making. Developing Post-Conventional ethical reasoning is the goal for nurses dedicated to providing care aligned with universal human values and rights.

The Kohlberg Heinz Dilemma is a powerful tool for exploring the depths of moral reasoning through the lens of Kohlberg’s theory of moral development. By grappling with this scenario, nursing students can systematically build their ethical skills – enhancing self-awareness, ethical sensitivity, ability to analyze competing perspectives, and application of moral principles.

Ethical competency is essential for nurses to navigate the increasing ethical complexities in healthcare, advocate for ethical practices, and ultimately ensure care that preserves human dignity. Mastering moral reasoning enables nurses to fully uphold their responsibilities as moral agents for their patients.

Related Articles:

Kohlberg’s Theory of Moral Development

Kohlberg’s Stages Of Moral Development


How can Kohlberg’s theory be applied in nursing?

Kohlberg’s theory of moral development can be applied to nursing practice in various ways, including understanding patients’ moral reasoning, ethical decision-making, patient education, and professional development.

What is the concept of Heinz’s dilemma in Kohlberg’s theory?

a story about an ethical dilemma faced by a character named Heinz that was used by Lawrence Kohlberg to assess the moral reasoning skills of those he asked to respond to it. Having exhausted every other possibility, Heinz must decide whether to steal an expensive drug that offers the only hope of saving his dying wife.

What is a moral dilemma in nursing?

the dilemma arises when the law or a medical issue related to the patient constitutes one thing, whereas the patient demands something else. A typical scenario when such an ethical dilemma would arise is if patient A, who is pregnant, has a history of congenital heart defects.

What are the ethical dilemmas for nurse students?

Contemporary ethical issues that nurses experience include protecting the rights of patients, patient autonomy and informed consent, end-of-life care, breaches of patient confidentiality, resource allocation including staff, and unethical practices of health care professionals, among others