A Snake in our Midst: The Constriction of Nursing Ethics by the Serpent Bioethics

It has been in our midst from the start, gliding through the thatched undergrowth of our history, now and again managing to coil itself around us, restricting our circulation, but never sufficient to stop the blood-flow to our heart. Or so some would think, though many would not notice.  But indeed the snake of biomedical ethics has wrapped its coils around nursing, has squeezed the vital organs of blood supply, until the ischemia has actually caused our heart and brain to stop. Such is the predation of medicine. Nowhere is this more apparent than at the heart of nursing – its ethics.

Staff of Aesculapius

From the coalescence of modern nursing in the US in the 1870s, ethics was seen as the life’s blood of the profession, to the degree that ethics amply suffused the nursing curriculum, claimed in addition its own subject course, was instrumental in the formation of nursing identity, guided practice, counseled the direction of the organized profession, and set a coherent vision for the role of nurses and nursing in society. This was not an informal, untutored ethics.  It was guided by a formal philosophy that was congruent with, and supportive of, the values, ends, aims, and ideals of nursing and the moral life of the nurse.[1]

Early nursing ethics established its foundation as relationally-based, in “classes of relationship.” Clara Weeks (Shaw) writes (1888) “…Your duties may be classified as threefold: those which you owe to yourself, those due to the physician under whose direction you work, and such as relate immediately to the patient.  Something is perhaps owing also to the school with which you are or have been connected.”[2]  In 1889, Harriet Camp, in her article “Nursing Ethics,” writes, “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.”[3] While the relationships are recombined and reconfigured over the decades, nursing ethics remained resolutely relationally-based and included nurse-to-self and nurse-to-society relationships. The current American Nurses Association (ANA) Code of Ethics with Interpretive Statements (2015) employs that relational motif.  It is a vestigial remnant of a now deceased but authentic nursing ethics.[4]

As nursing moved into universities and colleges, ethics education shifted from nursing faculty to departments of philosophy and theology, to be taught by those who had little regard for nursing, or nurses, or their feminist concerns.  Indeed, they were largely ignorant of the values, aims, and practice of nursing and, with one exception, cared little for educating themselves about nursing, and thought it unnecessary.  In addition, as nursing transitioned into colleges, its hospital-based libraries were not brought into the universities. The 100 textbooks dedicated to nursing ethics were largely lost, and certainly ceased to inform what was being taught to nursing students.

The serpent strikes, again, but this time it coils and constricts fatally. Nursing’s movement into universities occurred contemporaneously with the rise of medical technology which, in part, gave rise to a renewed medical ethics. Medical ethics, became biomedical ethics, became bioethics, but it was still the same old serpent, having shed its old skin for a newer one. Its tools were those of a priori, decontextualized, non-relational, abstract principles, and Continental philosophies that could be formulaically adapted and misused to address medical concerns, but it had (and has) little fit with nursing or nursing values, ideals, aims and concerns. Nursing uncritically adopted bioethics.  When its skin did not fit, it simply adjusted it, rather than shedding it. This commentary is a call to tame the serpent –it need not be killed for it has some utility in situations of relational breakdown.  However…

Bioethics is not nursing ethics.  Bioethics bears no resemblance to nursing ethics. Bioethics views nursing as a submedical occupation and is largely ignorant of nursing’s definition, practice, orientation, theory, philosophy, identity, values, duties…and neither encompasses nor incorporates these; and customarily does not mention nursing in its textbooks, other than in a token chapter written by a nurse(s). Bioethics is not beyond exploiting nursing for its own ends. However…

Nursing ethics is philosophically informed and robust.[5]  Nursing ethics is relational.  Nursing ethics is contextual, rooted in experience. Nursing ethics is about the moral character of the nurse and the instantiation of nursing identity.  Nursing ethics, rightly enacted, is an alloy of skilled nursing practice and ethical comportment; they are interfused and inseparable – one does not exist rightly without the other.  [Skilled practice + moral comportment] = good nursing, both morally and clinically. Nursing ethics is about the enactment of the values and ends of nursing within the context of each of the classes of relationship of nursing. Nursing ethics is a positive enterprise and is not conflict or problem-based. Because it is relational, nursing ethics is a preventive ethics; it seeks to build and preserve relationships.  Nursing ethics views nursing and the nurse with dignity and respect and care. Nursing ethics, ab initio, has been a social ethics, concerned for the right and good and fitting in the social structures that govern society and all its inhabitants.[6],[7],[8],[9] Nursing ethics addresses nursing concerns. Read its 100 textbooks (and editions),[10] 400 AJN articles,[11] ICN speeches, and more, from 1880—1965. Yes, you will have to wade through the late Victorian rhetorical style, vocabulary, and circumlocution; but read it and finally feel at home in the moral demands, identity, values, and milieu of our own ethics. 

It is time for nursing to grasp the snake of bioethics behind the head and toss it back into its own den.  Nursing is much better served by its own ethics.

[1] Fowler, Marsha.  Nursing Ethics: Its History and Development.  London: Routledge. Forthcoming.

[2] Weeks (Shaw), Clara. A Text-Book of Nursing.  NY: D. Appleton and Company, 1888, p.15.

[3] HCC [Harriet C. Camp]. “ The Ethics of Nursing: Talks of a Superintendent with Her Graduating Class,” part 1, The Trained Nurse. Vol. II, no. 5, May 1889, 179-183.

[4] American Nurses Association.  Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: ANA, 2015.

[5] Fowler, Marsha.  “Why the History of Nursing Ethics Matters,” Nursing Ethics, 2017, 24(3), 292-304.

[6] Fowler, Marsha D. “Nursing’s Code of Ethics, Social Ethics, and Social Policy,” Nurses at the Table: Nursing, Ethics, and Health Policy, special report, Hastings Center Report 46, no. 5 (Sept-Oct, 2016).

[7] Fowler, Marsha.  “Remembering the Future,” in Routledge Handbook of Philosophy and Nursing, ed. Martin Lipscomb. (London: Routledge, 2023). Forthcoming.

[8] Fowler, M.D.M.  “Nursing and Social Ethics,” in Chaska, N.A. (ed.), The Nursing Profession:  Turning Points, St. Louis:  C.V. Mosby, 1989, pp. 24-30.

[9] Fowler, Marsha D.M. Guide to Nursing’s Social Policy Statement: Understanding the Essence of the Profession from Social Contract to Social Covenant.  Silver Spring: American Nurses Association, 2015.

[10] Fowler, Marsha D.M. “Heritage Ethics: Toward a Thicker Account of Nursing Ethics,” Nursing Ethics. 23(1) 7-21, Feb 2016.

[11] Fowler, Marsha.   Nursing’s Ethics, 1893-1983:  the Ideal of Service, the Reality of History.  Los Angeles: University of Southern California.  1984.

17 thoughts on “A Snake in our Midst: The Constriction of Nursing Ethics by the Serpent Bioethics

  1. Marsha Fowler’s commentary on nursing ethics is passionate and provocative. As a non-academic nurse, I would welcome more detail about this position. Comparative examples between nursing ethical issues and biomedical/bioethical problems would be welcomed. Thank you for opening this experienced clinician’s eyes and mind! Beth White, MSN, RN

  2. Marsha -Thanks so much! Question: Why not write and promote a new book on nursing ethics, foundational to nursing practice at each degree level. As a practice text, it will require integration within clinical courses, where it’s applicability is greatest. Plus, it will be integrated vertically and even redundantly within a curriculum, where redundancy is a good thing in nursing education. In fact, it will serve as a fourth dimension in nursing practice, an umbrella encompassing the relational elements of prior three practice and research dimensions: diagnoses, interventions, and outcomes. What do you think? Thanks for opportunity to comment — Mary Ann

    • Thank you Mary Ann– I am doing just that — a book on nursing ethics—a real, satisfying, harmonious, nurturing, nursecentric, relational nursing ethics that is drawn from our amazing tradition! Working on it as fast as I can!

  3. The important distinction Dr. Fowler makes is right on point for me. I teach a bioethics course for nursing students. I am an ethicist, but not a nurse. I knew the four principles, however useful in the bioethics committees I serve on, did not adequately address the diverse nursing experience of my students. Dr. Fowler’s books and articles provided a historical context and clarified the robust quality of nursing ethics. It has made a significant impact on our curriculum and students!

    • Ahh, yes. Bioethics (as the 4 principles) is very helpful in two situations: (1) when on a hospital ethics committee because that is the language (and concepts) that is commonly used by physicians and ethics committees, and (2) when everything has fallen apart, devolved, or conflictual. Nursing ethics strives to maintain relationships, and by doing so head off relational fracture and conflict — it is a preventive ethics. But nursing ethics also affirms nursing practice in a circular way–nursing ethics informs nursing practice and nursing practice informs nursing ethics..

  4. Thank you, Dr. Fowler, for raising this great discussion. Besides the four main principles in nursing ethics (autonomy, beneficence, justice, non-maleficence), we also have nine provisions for the code of ethics for nurses, which I have found very meaningful for our practice.
    As you mentioned, nursing ethics is philosophically informed, involves professional practice and moral components. I think it focuses more on nurse-patient relationships.
    Bioethics is a broader term involving the moral dilemmas of the medical field. And since nursing as a discipline has its own ethical pillars, nursing ethics should not be combined with bioethics. Bio ethics does not provide the true meaning of nursing ethics under its umbrella.

  5. Ha, thanks Cathy but not sure it is a sentiment widely shared in part because it challenges the “received ethics” (bioethics) and its usefulness in nursing.

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