American nursing has an extraordinary body of nursing ethics literature from the 1880s to the mid-1960s. This literature developed prior to the rise of the field of medical ethics (later termed biomedical ethics, then bioethics) in the mid-1960s, and bears little resemblance to its later counterparts. Early nursing ethics was nurse-centric; relationally based; addressed nurses’ ethical comportment in all roles; advanced the social ethics of nursing (especially in response to health disparities); and set forth ethical expectations for the profession as a whole. This first wave of nursing ethics is distinctive and differs significantly from contemporary bioethics, yet it remains grossly under-researched. It offers nurses a wise, comprehensive, generous, and learned ethics that deserves to be reclaimed for today’s nursing practice. This article will offer an author backdrop and an historical review of early nursing ethics literature; consider the nursing profession as a calling; discuss the pivot to bioethics and the Code of Ethics as anomaly.
Key Words: Nursing ethics, virtue, social ethics, ethics, etiquette, bioethics, moral, nursing, history, Code of Ethics, relationships, comportment, calling, vocation
American nursing has an extraordinary body of nursing ethics literature from the 1880s to the mid-1960s. American nursing has an extraordinary body of nursing ethics literature from the 1880s to the mid-1960s. This literature developed prior to the rise of the field of medical ethics, (later termed biomedical ethics, and then bioethics) in the mid-1960s, and bears little resemblance to its later counterparts. Early nursing ethics was nurse-centric; relationally based; addressed nurses’ ethical comportment in all roles and nursing notions of the good; advanced the social ethics of nursing (especially in response to health disparities), and set forth ethical expectations for the profession as a whole. This first wave of nursing ethics is distinctive and differs significantly from contemporary bioethics, yet it remains grossly under-researched. The profession of nursing has lost sight of its tradition of collective ethical wisdom, one that crafted an ethics that would and could sustain nursing practice, even today. It offers nurses a wise, comprehensive, generous, and learned ethics that deserves to be reclaimed for today’s nursing practice.
In the late 1970s, I was fresh from completing a Joseph P. Kennedy, Jr. Fellowship in Medical Ethics. There were 19 nurses who held this fellowship over a period of ten years (Fry, Collopy, & Duffy, 1996). During the fellowship year, the fellows were all schooled in medical ethics, which subsequently came to be called biomedical ethics, and then bioethics. The fellowships were led by Georgetown and Harvard faculty, so the nurse-fellows were well schooled in principles of respect for autonomy, nonmaleficence, beneficence, and distributive justice, and were well equipped to take this knowledge into hospital ethics committees and the nursing venues in which they served. However, in the process of deciding my dissertation topic these principles did not call to me. Instead, I was attracted to the then current 1976 ANA Code of Ethics for Nurses with Interpretive Statements (Code) which had a depth and profundity that captivated me (American Nurses Association [ANA], 1976). My dissertation topic became an examination of every iteration of the Code, and Lystra Gretter’s 1893 Nightingale Pledge (Gretter, 1893) within its social context, to look at its progress and the social and ethical forces that shaped and informed it (Fowler, 1984).
...I discovered a breathtaking, fulsome literature in nursing ethics, written by nurses for nurses. The collateral findings of the dissertation were as important as the dissertation itself. In the journey through the nursing code revisions, across almost 100 years, I discovered a breathtaking, fulsome literature in nursing ethics, written by nurses for nurses. It is an informed, insightful, extensive, embodied, situated ethics that is fully responsive to the values, obligations, and practice needs of nursing.
Early Nursing Ethics Literature
These text books moved directly from ethics to enemas in short order The period of the late 1800s to the mid-1960s (when bioethics rises as a discipline), represents the first wave of nursing ethics, what can be termed nursing’s heritage ethics, or preferably, nursing ethics. Most nurses in ethics are aware of Isabel Robb’s 1900 book Nursing Ethics, usually considered to be the first modern U.S. nursing ethics book. There are journal articles and book chapters that predate Robb’s publication. For example, Harriet Camp wrote an 1889 article series, titled “Nursing Ethics,” published in six sequential issues of the Trained Nurse and Hospital Review (HCC, 1889). In the late 1800s, however, early clinical textbooks contained a first chapter devoted to nursing ethics, though the content that followed was entirely clinical. These text books moved directly from ethics to enemas in short order (Fowler, 2017).
The content of early non-nurse authored books differs dramatically from that of the nurse-authored books Robb’s book does not stand alone. There are approximately 100 textbooks and editions on nursing ethics between 1900 and 1964. These are specifically ethics textbooks, usually bearing the title “Nursing Ethics,” though in the 1950s they are re-titled “Professional Adjustments, Volume 1” (Fowler, 2016a). In any given year from 1900 to 1965, there were no fewer than two and as many as eleven nursing ethics textbooks in print and in general use. Most were written by nurses, though some by priests, pastors, physicians, and a psychologist. Those texts by physicians, priest-theologians, and a small number of other non-nurses, were usually titled “medical ethics for nurses,” and after the 1970s, “bioethics for nurses.” The content of early non-nurse authored books differs dramatically from that of the nurse-authored books (Fowler, 2016a).
The ethics literature is far more extensive than what exists in these textbooks alone. Between 1900 and 1980 there were over 400 articles in the American Journal of Nursing that were principally devoted to ethics (Fowler, 1984). From the 1920s, the NLN(E) had specific, mandated curricular requirements for ethics education, as did various state Boards of Registered Nursing. That content specifically included social ethics. There are ethics lectures given at international nursing congresses for the International Council of Nurses (ICN) founded in 1899, and at the national ANA meetings, many of which were reprinted in journals in the United States (US) and United Kingdom (UK) (Fowler, 1984). One can also find countless nursing commencement addresses on ethics in nursing. In addition there are ethics questions on nursing licensure exams (Fowler, 2016a, pp. 10-15; 2017, pp. 292-304).
Hospital libraries were not brought over into the universities, and ethics education shifted from nursing faculty to departments of philosophy and theology. Much of this literature had been lost when, after the 1965 ANA position statement on nursing education (ANA, 1965), nursing moved from hospital-based schools to colleges and universities. Hospital libraries were not brought over into the universities, and ethics education shifted from nursing faculty to departments of philosophy and theology. This shift, and the concomitant loss of these works, occurs contemporaneously with the rise of the field of bioethics. These works have now been identified and collected, and are now available to doctoral and other nursing ethics researchers in the Nursing Ethics Heritage Collection at the University of Surrey.
As a pristine, un-researched, body of works by and for women, this collection has attracted the attention of scholars in literary criticism and women’s studies, as well as nurse scholars. Yet, to date, there has been no nursing analysis of this extensive collection of nursing ethics literature other than a preliminary incursion that identifies the works themselves; examines the influence of the social context on the shape of this literature; and discovers some of the larger themes and motifs (Fowler, 2017). Further research is needed both comprehensively and topically; many of the topics (e.g., moral courage) in this heritage literature are also contemporary concerns.
Themes and Motifs
Ethics Education as Moral Formation
Early modern nursing, from the founding of nursing schools in 1873 forward, viewed ethics education as essential, and held that the role of nursing education was equal parts nursing preparation and moral formation. It was tied primarily to a virtue-based ethics that also included a specification of concrete moral responsibilities. Nursing leaders believed that the educational environment must work, first, to shape the nursing student into a moral being imbued with notions of good in their nursing identity and practice, and second, to provide specification of what is right and wrong for the nurse to do.
Nursing’s virtue-based ethics also attended to etiquette.Nursing’s virtue-based ethics also attended to etiquette. Issues of etiquette were seen as outward evidence of one’s inner virtue, so the two are addressed together. Etiquette, patterned after military discipline, resided in the interstices of relationships and dictated behaviors in personal interactions; it made diplomacy and communication, even relationship, possible. The emphasis on moral character formation in addition to nursing education also embodied cultural and period norms for class, education, and gendered roles, for “womanhood.” The incoming student, known as a probationer, was seen as a morally and educationally unformed girl who must be shaped into a morally good woman, nurse, and citizen. Isabel Robb wrote [Note: the spelling and gendered languagewithin all quotes has been left as originally written.]:
... the training school of a hospital may, therefore be regarded as a place not only for fitting women to properly undertake the care of the sick, but as an educational institution, where properly selected women are given such educational advantages that they can go forth equipped and ready to aid in the practical solution of social problems, which are to be mastered only by the help of intelligent womanly work. (Robb, 1900, p. 47).
That educational advantage specifically included “systematic” ethics education. Robb wrote:
Instruction in the science of ethics and the rules of etiquette should be commenced from the moment the pupil-nurse enters a hospital, and from the very beginning of her term of probation. It should go hand in hand with the training in the theory and practice of nursing, otherwise the pupil will fail to realize its proper degree of importance and thus much benefit will be lost to her. Such instruction should be practical and systematic, beginning with the moral laws and rules she will need first to put into practice, and progressively leading up to an appreciation of her greater and higher obligations to herself, to her profession and to humanity. (Robb, 1900, p. 16)
...instruction in ethics began at the outset and suffused the entire curriculum In early nursing education, instruction in ethics began at the outset and suffused the entire curriculum; it was not confined within a single course never to appear again. Early nursing education was a matter of development and support of virtues with a clear specification of concrete duties.
Virtues: The Moral Character of the Nurse
The ethics heritage literature, from the 1880s to 1965, discussed a wide range of virtues and excellences that are to be cultivated and modeled among nursing students and nurses, always situated within the context of nursing practice, the several nursing relationships (discussed below); and the community, bonds, and tradition of nursing. Many virtues that span a wide range virtues were discussed, including:
- Doing one’s work decently and in order
- Avoiding impropriety
- Being a force for good
- Maintaining self-discipline and shunning personal laxity
- Unflinchingly standing firm on what one knows to be morally right
- Exercising moral pluck
- Voluntary observance of institutional rules and standards
- The exercise of self-discipline in ways that affirm personal moral and intellectual growth as well as both individuality and community
- Loving one’s nursing work
- Being liberally (that is, broadly) educated
- Embracing an egalitarian respect for all regardless of social station or economic status
- Genuine compassion, empathy, and kindness
- A love for humanity
These are attributes of moral character that cannot be understood or communicated except within the immersive and lived experience of nursing practice within the community of nursing.
Moral courage is discussed in both the U.K. and U.S. heritage literature from at least the 1880s, yet it finds its way into contemporary nursing ethics literature as if it were a new concept. Charlotte Aikens, in Studies in Ethics for Nurses (1923), wrote that executive ability in the nurse requires “these two striking and important traits of character—moral courage and self-reliance. These two might be combined in the well-understood quality known as back-bone” (Aikens, 1923, p. 197). Moral courage is discussed in both the U.K. and U.S. heritage literature from at least the 1880s, yet it finds its way into contemporary nursing ethics literature as if it were a new concept. In her 1925 work, Ethics: A Text-Book for Nurses and Lesson Plans for Schools of Nursing Applying Ethical Principles to Nursing Problems, Charlotte Talley included a section for students about acquiring and practicing specific virtues, in order to develop them. She advises several exercises including reflection on specific virtues; observing and examining instances of a particular virtue; keeping a notebook of these instances; and weekly self-examination (Talley, 1925).
Nursing as a Vocation, Calling, Profession
The discussions of virtue and nursing-as-calling are utterly intertwined and inextricable.While the literature assumes that nursing is a profession, it simultaneously embraces the profession as a vocation or a calling, and gives attention to the implications of this for moral character. The discussions of virtue and nursing-as-calling are utterly intertwined and inextricable. A concern about nursing as profession-versus-vocation is typified by Evelyn Pearce’s words:
Nursing, like medicine, is a honourable service and honour will always be accorded to those who follow it. Many take up nursing from altruistic motives: they have a great desire to help others, and it is their innate kindness which inspires the desire to train and become proficient in nursing. Some do it merely to earn a living: to them it is a career, but as nursing is essentially humanitarian, it is doubtful whether it can be as well done when it is taken up simply as a career than when it is inspired by a spiritual ideal (Pearce, 1953, p. 78).
This is a late (1953) statement in the literature but it is consistent with concerns throughout the heritage literature to retain a caring, even loving, humanitarian nature to the art of nursing, even while nursing scientizes and professionalizes, and to have practitioners for whom nursing is an inner identity and a calling. There are two streams of discussion that follow: first, the nature of nursing education, and second, of just remuneration versus the exploitation of nursing labor.
For example, Isabel Robb addressed both these concerns when she wrote:
In speaking of nursing as a profession for women, I have used the term advisedly. Some prefer the term vocation, or the Anglo-Saxon word, calling. The last, if made to bear the significance of a direct call from God to a consecrated service, would rather suggest, on first thought, a sisterhood with its religious restrictions: and surely profession means all that vocation does and more. The work of the clergy, the lawyer and the physician is spoken of as a profession; the term implies more responsibility, more serious duty, a higher skill and an employment needing education more thorough than that required in some vocations of life. Every day these qualities are more and more being demanded of the trained nurse by modern physicians and exacting laity… (Robb, 1900, pp. 32-33).
She then stated that:
The trained nurse, then, is no longer to be regarded as a better trained, more useful, higher class of servant, but as one who has knowledge that is worthy of respect, consideration and due recompense—in a certain degree a member of a profession… (Robb, 1900, p. 37).
Ethical Issues in Early Nursing Ethics
...virtually every ethics topic found in contemporary nursing ethics books appeared in the much earlier books as well...Moving to more topical concerns in the early literature, virtually every ethics topic found in contemporary nursing ethics books appeared in the much earlier books as well, and forms threads throughout the nursing ethics heritage literature. The first extant example of actual research on moral problems in clinical nursing is found in Sr. Rose Hélène Vaughn’s 1935 master’s degree thesis The Actual Incidence of Moral Problems in Nursing: A Preliminary Study in Empirical Ethics (Vaughn, 1935). The purpose was "to obtain empirical evidence regarding the incidence of questions, doubts, and problems which were confronting the modern nurse, in order to learn the outstanding difficulties, present in the lives of a large number of nurses" (Vaughn, 1935, pp. 3-4).
The moral problem of greatest frequency was “cooperation between nurses and physicians.” Vaughn asked nurses to keep diaries of clinical incidents. She identified 2,366 ethical incidents, which she sorted into 33 categories. The moral problem of greatest frequency was “cooperation between nurses and physicians.” The largest category, overall, was that of “cooperation,” including between physician and nurse; among nurses, with supervisors; between nurse and patient relative(s); and, interestingly, in “matters of asepsis.” Examples of her other categories of “incidents” included lust (sexual harassment), lying (dishonest charting), vulgar and profane language, justice, negligence, restitution, and more.
Despite these “incidents” the early ethics literature differs from contemporary nursing ethics literature in that it is not problem-oriented; it is virtue-oriented, relationally-oriented, and call or vocation-oriented, and these form the strands within which problems might be discussed and addressed. Note that virtue ethics does not lead to breakdown or dilemma-based ethics; it leads to relationally-based ethics, an aim of which is to avert ethical problems or conflict; it is a “preventive ethics.”
Early nursing ethics is relationally-based.Early nursing ethics is relationally-based. As has been noted elsewhere (Fowler, 2017) the earliest American journal articles on nursing ethics (1889) begin by identifying seven classes of relationship:
For convenience sake, I will divide the duties of a nurse into seven classes: 1st. Those she owes to the family 2nd. Those she owes to the doctor. 3rd. Those owing the family, friends, and servants of the patient. 4th To herself. 5th. To her own friends. 6th To her own hospital or school. 7th. To other nurses (HCC, 1889, p. 179).
Note that since nursing took place in the home, the patient and her or his family were the locus of concern; the patient was not simply the individual sick person. Through the years the number of classes of relationship would be reduced and reconfigured. The heritage literature follows a relational motif in articulating the duties that accrue to the nurse within each class of relationship. It is a “ground-up” articulation that has much in common with contemporary feminist ethical critiques that begin with the lived experience of women. From the start, this, gives nursing a structure within which to categorize nursing’s ethical responsibilities, concerns, values and ideals. Many of the nursing ethics heritage books organise their chapters within this relational framework. Some books address only one relationship: nurse and patient. Let us move now to a few examples of ethical concerns within the assorted nurse relationships.
Professional secrets is broader than and cannot be reduced to the contemporary discussions of confidentiality...The Nurse - Patient Relationship. A concern for professional secrets is an early and enduring concern within the context of the nurse-patient relationship, and one that predominates in the literature. I have written about this elsewhere (Fowler, 2017) but in brief, professional secrets are information that the nurse receives or observes, in the course of nursing practice, about the patient and family that is personal in nature, and that the nurse must then decide whether or not to disclose to the physician. Professional secrets is broader than and cannot be reduced to the contemporary discussions of confidentiality, largely because discussions of professional secrets are rooted in a relationship of trust, whereas discussions of confidentiality are usually contextualized within the context of patient rights.
Nurses kept these secrets as professional secrets within nursing...The term medical secrets was used in the nursing ethics textbooks written by physicians or clergy, whereas those works written by nurses used the term professional secrets, and professional referred specifically to nursing, and not medicine. Nurses recognized that not all of the secrets shared with them, or observed, were of a medical nature. As nursing took place in the home, these secrets could pertain to anything or anyone in the household, whether family or not, and were not limited to the ill person or the illness. Nurses kept these secrets as professional secrets within nursing; the nurse made a judgment of what or what not to share with the physician. The early literature also speaks of nurses’ duty of conscience, that is, the duty to form, hold, and act upon one’s own moral judgments in patient care.
Nurse-to-Self (Duties to Self). Duties to self loom large (and uniformly) in the early nursing ethics textbooks. In the earliest general textbooks on nursing, the first chapter was often devoted to ethics under the title “responsibilities of the nurse.” Emily Stoney, in her 1896 general textbook Practical Points in Nursing for Private Practice wrote:
A nurse should improve her mind by reading the best books at her command, by going out and visiting friends, and by attending the theater twice a month; this will keep her in touch with outside affairs, and she will be able to converse intelligently with her patients (Stoney, 1896, p. 18).
Isabel Robb, too, addressed the nurse’s duties to self, including a daily hot bath in the evening for cleanliness and to aid sleep, vigorous brushing of the teeth, meals taken regularly, a “regular amount of well-ordered recreation,” two weeks of vacation (required!), ongoing reading, and attending alumni association meetings. In 1930 Gladwin wrote:
Because the body furnishes the only medium for self-expression and through it the mind and spirit, the real self, are revealed, her first duty to herself is to make her body as perfect an instrument as she possibly can (Gladwin, 1930, p.73-74).
Gladwin discussed the mind-body connection, and the advantage of striving for perfect interrelated sanity [health] of body, mind, and spirit (Gladwin, 1930).
While it is noted that one must be healthy to give good nursing care, (that is, health as an instrumental good) these works see health as an end in itself for the sake of the well-being of the nurse. This strand of ethics does not appear in contemporary bioethics, though it is found in the ANA Code of Ethics for Nurses from 2001 forward. (Fowler, 2015a)
The Nurse-to-Nurse Relationship. Robb called for “true harmony” and an “esprit de corps” among nurses (Robb, 1900, p.144). A number of writers speak of the “tone of a school” or the “tone of the hospital” both of which are discussions of the moral tone, or what today is called the moral environment of education or practice.
There is a thread in the ethics literature of a potential danger within nursing. In a discussion of friendship, Charlotte Aikens wrote: “It is hard to keep one’s affections always within safe limits, yet it is just as well to know that friendship has its dangers, and to guard against these dangers when possible.” (Aikens, 1923, p. 209). Robb, too, warned nurses about friendships: “Sentimental, intense personal friendships between nurses are a mistake, and are rarely productive of good. In some instances, they must be regarded as forms of perverted affection; they are always unhealthy…” (Robb, 1900, p.140). By 1942, Goodall became somewhat more direct, in an indirect kind of way. She wrote:
In dormitory life or in any other way of life, avoid crushes for they will rob you of all healthy, natural desire to mingle with groups of people and within your life they will harbor evils and miseries that jealousy can bring. When carried too far, they will turn your emotions from their natural bent and cause you to have an unnatural and unhappy attitude toward men…the best rule in friendship is to be fond of many and familiar with none (Goodall, 1942, pp. 175-6).
There is a fear evident within the early nursing literature that placing women in required shared living quarters (dormitories) could cause them to become lesbian; the best way to avoid this is to restrict friendships and familiarity.
The Nurse-to-Physician Relationship. The relationship with the physician, including concerns for medical incompetence or negligence, sexual harassment, and verbal abuse, was substantial but tended to be addressed rather cryptically. From the start, there was a concern for incompetent physicians, but even more, for a terrible tension for the nurse who must be loyal even to an incompetent physician, yet whose priority and first allegiance is to the patient. Robb (1900) took great pains to explain that the nurse is not qualified to judge a physician’s ability or to question his treatments, neither may she ever criticize the physician to the patient or family. At some point however, Robb had to give a nod to reality and she wrote:
If a nurse has made up her mind that a physician is incapable, she can always find some means of refusing to take charge of the nursing of his patients, but once having put herself under him, let her remain loyal and carry out his orders to the letter. Nor is it honorable in the nurse ever to cast discredit in any way upon the physician… (Robb, 1900, p. 251).
When the issue is not expressly physician incompetence, but abuse, she wrote:
But if truth must be told, rare instances occur in which the physician is unworthy of the respect both of the nurse and patient,…she [the nurse] is not expected to put up with unjust or rude behavior…she is fully justified in leaving the case as soon as an efficient substitute has been found to take her place (Robb, 1900, p. 257).
For Robb, any question about the competence or appropriateness of medical care must come from the patient or the family, not the nurse.
Gladwin is perhaps one of the more direct commentators on medical malpractice and the nurse. In 1930, she wrote:
The question of the inefficiency or malpractice of a physician may arise. There are, unfortunately, unworthy men in the medical profession, just as there are nurses without conscience or honor…No rule can be given to serve as a safe guide on all occasions…The atmosphere is sometimes cleared when the nurse remembers that she owes her first allegiance to her patients. No nurse should sow seeds of doubt regarding the physician’s work in the mind of the sick one but it may be her duty to lead the family to think of a consultation. She should not yield to her first impulse to throw up the case, but should remember that the patient who has fallen into the hands of a quack or a dishonest, inefficient practitioner needs her much more than more fortunate ones,...nurses have helped physicians to save many lives and occasionally a nurse has saved a life in spite of a physician (Gladwin, 1930, pp. 105-6).
By the 1940s and 1950s (after Nuremberg), the literature began to include discussions about human rights.The Nurse-to-Society Relationship (Social Ethics). Discussions of nurses’ relationship to society pervade the early literature and were usually discussed under the topics of citizenship, democratic ideals, or democracy, and love for humanity. By the 1940s and 1950s (after Nuremberg), the literature began to include discussions about human rights. From early days there was a concern for those living in poverty who required nursing care, for the social construction of poverty and illness, and for health disparities (Fowler, 2015b; 2016b; 2020). Aikens wrote:
The established order of things sometimes has to be upset before much progress can be made. There are conditions that are not right in regard to nursing which should be worked at till better conditions are assured. In the private nursing field especially, nurses are most unequally distributed—patients who sadly need their skill are unable to secure it; nurses who seriously need work are held back from accepting calls to nurse where their help is sorely needed. (Aikens, 1923, pp. 230, 250).
Aikens called for nurses to have a pioneering spirit and to pioneer nursing service beyond the established order of things (Aikens, 1923).
The Pivot to Bioethics
In the 1960s and forward, as nursing moved into colleges and universities, nursing’s heritage ethics was left behind and forgotten in a convergence of events, a few of which will be noted here. As noted above, the heritage literature did not follow nurses into colleges. In addition, ethics education, which had been the province of nursing school directors, was shifted to philosophers and theologians who did not understand or have any familiarity or identity with actual nursing practice beyond that of the lay public.
From the late 1960s onward, nursing’s heritage ethics is largely unknown.From the late 1960s onward, nursing’s heritage ethics is largely unknown. In this period there is also an unparalleled advance of medical technology and the development of a range of intensive care units, and medical sub-specializations. With this, there was also a rise in the field of medical ethics that, as it developed, came to be called biomedical ethics, then bioethics, though it remained largely medically identified, medically normative, and centered on issues in medicine.
Medical ethics filled the void left by the demise of nursing ethics, but its concerns were completely different, medically-centered (e.g. physician paternalism, withdrawal of life sustaining treatment, futility) and constituted a radical disjunction. The philosophers and theologians who assumed the task of teaching ethics to nurses were ignorant of the mature and pervasive nursing ethics that predated the rise of bioethics. Moving nursing ethics to philosophers and theologians undercut the notions of good embedded in nursing practice, or practice-based ethics (MacIntyre, 2007), and did not embrace or express the values and ideals of nursing.
Medical ethics filled the void left by the demise of nursing ethics...The Joseph P. Kennedy, Jr. Fellowships in Medical Ethics were instituted in order to offer a few nurse educators post-doctoral education in ethics, or more specifically, in medical ethics, at Georgetown and Harvard Universities. In addition, the Kennedy Institute of Ethics began offering an intensive medical ethics course, now in its 44th year. Those nurses who received the Kennedy Fellowship, and who attended the Georgetown Intensive course, were tapped to participate on hospital ethics committees, to teach ethics in nursing schools, to conduct research in ethics, and to write the new generation of nursing (bio)ethics textbooks.
In the same time period, Tom Beauchamp and Jim Childress published their renowned work Principles of Biomedical Ethics in 1979 (Beauchamp & Childress, 1979). The Belmont Report (National Commission, 1979) was also published that same year. Both works advanced ethical principlism in the healthcare and research communities. Principalism uses abstract, non-contextual, non-situated, analytical, ethical principles to examine ethical problems, the antithesis of the way in which nursing virtue and practice-based ethics had proceeded.
The bioethics texts of that day, and even to the present, rarely mentioned nursing and did not address nursing concerns. These principles proved extremely useful as a shared ethics language with medicine, and when staff was confronted with medical dilemmas or crises. By the late 1970s to 1980s, those involved in ethics in nursing, myself included, had mostly uncritically adopted bioethics, whole cloth, until the subsequent rise of various critiques of that literature. The bioethics texts of that day, and even to the present, rarely mentioned nursing and did not address nursing concerns. Nursing faculty adopted and adapted the received principles for their application to nursing dilemmas, and a new, second wave, of ethics literature for nursing ensued.
The first nursing-bioethics textbooks focused on problematized ethical issues, dilemmas, and decision-making in order to construct for nursing a nursing ethics based on dilemma or breakdown ethics. Notions of good practice and virtues essential to good nursing practice fell to the wayside. Practice deficits, breakdowns, and dilemmas reigned, rather than the positive-project of instantiating the notions of good or virtues central to good nursing practice that had been in the forefront in nursing ethics prior to bioethics.
The prevailing error was that nursing already had a nursing ethics, but it had simply been forgotten.The prevailing error was and is that nursing already had a nursing ethics, but it had simply been forgotten. This positive project of nursing ethics is what needs to be reclaimed. Bioethics, with its tools for addressing breakdown ethics, could then be incorporated for its usefulness in dilemmas and for communicating with medical colleagues in a shared language. As the profession of nursing moved away from nursing ethics and into bioethics, there was, however, one persistent, nagging, vestige that should have signaled the existence of a prior, nursing-focused ethics: The ANA Code of Ethics for Nurses with Interpretive Statements (Code) (ANA, 2015).
The Code as Anomaly
In an era of nursing bioethics the Code (ANA, 1965, 1976, 2015) is a glaring anomaly. With origins in the late 1800s, and successive revisions for over a century, the Code represents the “old magik” that resides in nursing ethics before there was a bioethics. Despite efforts in the 1984 Code revision to incorporate more of bioethics, its inclusion was limited largely to language, but did include some concepts such as privacy, confidentiality, self-determination, and informed consent. Even these have some nuanced predecessor expressions in the nursing ethics literature, as in the professional secrets mentioned above.
The Code continues and advances an enduring nursing ethics...The Code continues and advances an enduring nursing ethics with its renewal approximately every 10 years. The Code is neither derivative nor representative of bioethics. Its contents retain a relational structure and explicate the duties of nurses within each of the several relationships. It has an enduring concern for a broad social ethics; and addresses issues, values, and ideals central to nursing ethics that do not appear in the general bioethics literature, and sometimes not even in the nursing bioethics literature. In the 2001 as our committee presented, to the ANA House of Delegates, the draft revision of the Code, several nurses took to the microphone, in tears, asking that the Code not be changed because “I love this Code.” They could not conceive that it could continue to become better even than it was. The Code deserves that love as it is a code by nurses, for nurses, and addresses nursing with a deep intimacy and abiding familiarity born of generations of nursing experience, practice, and tradition. It should, in itself, point us back to our heritage of nursing ethics and prompt us to reclaim that ethics for a new day.
Nurses need to delve deeply into the century of early nursing ethics literature in order to come to an authentic expression of nursing ethics that is not simply a re-tooled medical or bioethics. In 1984, a great friend of nursing, Andrew Jameton, wrote that:
Nursing is the morally central health profession. Philosophies of nursing, not medicine, should determine the image of health care and its future directions. In its anxiety to control the institutions and technology of health care, medicine has allowed the central values of health care - health and compassion - to fall to the hands of nurses. Nurses thus supply the real inspiration and hope for progress in health care, and among health professionals, represent the least equivocal commitment to their clientele (Jameton, 1984, p. xvi).
He is correct. Solid work in nursing ethical heritage will demonstrate that nursing ethics is and can be superior to all others in its service to the ethical needs of nurses and nursing. Nurses have 100 years of nursing ethics, before bioethics, that is virtue and practice-based, wise, thoughtful, extensive, and informed. Yet it has lain fallow and forgotten for the past 150 years as bioethics usurped and colonized nursing ethics. The nursing ethics literature from the 1800s to the 1960s, and the successive revisions of the Code, beckon us to gather the harvest bounty that is offered toward an authentic expression of nursing ethics.
Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, RSA
Dr. Fowler holds a PhD in Social Ethics and has researched the history and development of US nursing ethics for 40 years. She held a Joseph P. Kennedy Jr. Fellowship in Medical Ethics at Harvard University, and is the recipient of the ANA Honorary Human Rights Award. She recently completed a Fulbright Research Award to research the history and development of nursing ethics in the UK. Dr. Fowler has served the ANA as
- Committee on Ethics, member, 1985-87
- Chairwoman, Committee on Ethics, 1987-89
- Consultant to the task force, for revision of the 1984 Code for Nurses
- Project team, evaluation for revision of the Code for Nurses, 1995
- Member, task force for the Revision of the Code for Nurses with Interpretive Statements, 1996--2001
- Member, Task Force for the Review of the Code of Ethics, 2012-2013;
- Member, Steering Committee for the revision of the Code of Ethics for Nursing with Interpretive Statements; designated committee Historian and Code Scholar, 2013-2014
Dr. Fowler is currently serving on the writing subgroup for the revision of the code of ethics of the International Council of Nurses, 2019-2020.
Aikens, CA. (1923). Studies in ethics for nurses. 2nd ed. rev. Philadelphia, PA: WB Saunders, 1923.
American Nurses Association (1965). A position paper. New York, NY: American Nurses Association.
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Beauchamp, T, Childress J. (1979). Principles of biomedical ethics. New York, NY: Oxford University Press.
Fowler, MD. (1984). Nursing's ethics, 1893-1983: The ideal of service, the reality of history. [Dissertation. University of Southern California]. DigitalGeorgetown. Retrieved from https://repository.library.georgetown.edu/handle/10822/800987
Fowler, MDM. (2015a). Guide to the code of ethics for nurses: Development, interpretation and application. 2nd ed. Silver Spring: American Nurses Association.
Fowler, MDM. (2015b). Guide to nursing’s social policy statement: Understanding the essence of the profession from social contract to social covenant. Silver Spring, MD: American Nurses Association.
Fowler, MD.M. (2016a). Heritage ethics: Toward a thicker account of nursing ethics, Nursing Ethics. 23(1) 7-21. doi: 10.1177/0969733015608071
Fowler, MD. (2016b). Nursing’s code of ethics, social ethics, and social policy. Hastings Center Report 46(5), S9-S12. doi: 10.1002/hast.624
Fowler, MD. (2017). Why the history of nursing ethics matters. Nursing Ethics. 24(3) 292-304. doi: 10.1177/0969733016684581
Fowler, MD. (2020, in press) The influence of the social location of nurses-as-women on the development of nursing ethics. In Kohlen, H., McCarthy, J. (Eds.) Nursing ethics: Feminist perspectives. London: Springer.
Fry, S. Collopy, K. Duffy, M. (1996). The Kennedy nurse fellows in medical and nursing ethics, 1976-1996: A report of their professional accomplishments and contributions to health care ethics. Washington, DC: The Joseph P. Kennedy, Jr. Foundation.
Gladwin, ME. (1930). Ethics: Talks to nurses. Philadelphia: WB Saunders.
Goodall, PA. (1942). Ethics: The inner realities. Philadelphia, PA: F.A. Davis. 175-6.
Gretter, L. (1893). The Florence Nightingale Pledge. Detroit: Farrand Training School for Nurses, Harper Hospital. Photograph of the original autograph manuscript.
HCC [Camp, HC]. (1889). The ethics of nursing: Talks of a superintendent with her graduating class. The Trained Nurse, 2(5) 179-183.
Jameton, A. (1984). Nursing practice: The ethical issues. New Jersey: Prentice Hall.
MacIntyre, A. (2007). After virtue: A study in moral theory. Notre Dame, IN: University of Notre Dame.
The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Department of Health, Education and Welfare. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. Washington, DC: USGPO.
Pearce, EC. (1953). Nurse and patient: An ethical consideration of human relations. London: Faber & Faber.
Robb, IAH. (1900). Nursing ethics: For hospital and private use. New York, NY: E.C. Koeckert.
Stoney, EAM. (1896). Practical points in nursing for private practice. Philadelphia: WB Saunders.
Talley, C. (1925). Ethics: A text-book for nurses. NY: GP Putnam.
Vaughn, RH. (1935). The actual incidence of moral problems in nursing: A preliminary study in empirical ethics. Dissertation. Washington, DC: Catholic University Press.