Book Review – Nursing Ethics, 1880s to the Present: An Archaeology of Lost Wisdom and Identity by Marsha D. M. Fowler, PhD, MDiv, MS, RN, FAAN
One of Nursology’s assumptions—the one that is foundational to nursing as a discipline—is our assurance of who we are, what we know, and how we discover our knowledge. While Nursology draws on and intersects knowledge from other disciplines, our knowledge remains the distinct foundation for the autonomous praxis of nursing. Ethical Knowing is a fundamental pattern of knowing in nursing (Carper, 1978).
Nursing Ethics, 1880s to the Present: An Archaeology of Lost Wisdom and Identity (Fowler, 2024) offers a thorough historical account of the foundation of Ethical Knowing in nursing. Author Marsha Fowler is one of the most influential ethical philosophers of nursing. Her previous collected works provided the seminal study of ethical philosophy in nursing, from her own dissertation examination of every iteration of the ANA Code of Ethics and the Nightingale Pledge; by her analysis of our profession’s Social Policy Statement (American Nurses Association, 2015), and ongoing contributions to the American Nurses Association Code of Ethics (American Nurses Association, 2015; 2025) and International Council of Nursing Code of Ethics for Nursing (2021); and volumes of works in between.
Now, with Nursing Ethics, 1880s to the Present, Fowler takes her place as the authoritative historian of the development of nursing ethics. Acknowledging she is not formally trained as an historian, nevertheless Dr. Fowler is faithful to standards of historical discovery and thinking. She meticulously examined hundreds of primary sources and nursing ethics books from the 1880s through to the 1960s to uncover a fulsome and nuanced analysis of nursing’s ethics history. Her deep-rooted training in the philosophy of ethics serves Dr. Fowler’s interpretation of how pragmatism, as a school of thought, provided the foundation for Ethical Knowing in nursing.
Fowler explains how ethics functions in the professions, then writes about how pragmatists and progressives influenced the emergence of modern nursing, “within which nursing exercised its social ethics and practice” (p. 326). She places nursing ethics history in the context of emerging feminist activism as part of the first period of the social ethics movement. The progressive movement was born from pragmatism. Fowler explains how nurses and social workers in the progressive movement, Lavinia Dock, Lillian Wald, Adelaide Nutting, Jane Addams, Isabel Robb and colleagues John Dewey, and others, took right action to care for poor families in their homes and communities; to engage in unionizing for worker protection; to protect children, and take on the concerns of social health and welfare. Fowler shines a light on how the early progressive nursing leaders were feminists, and how feminist thinking infused their ways of being nurses, giving way to an ethics of care.
Dr. Fowler gives an account of how Protestant, Jewish and Catholic theological teachings imbued a ‘Social Gospel’ in the academic preparation of nurses in the US, Canada and the UK. ‘Liberation Theology’ permeated Catholic universities where nursing students were immersed in extensively studying theology and religion. Nursologists who have studied the origins of Emancipatory Knowing in Nursing will resonate with Fowler’s description of the influence of ‘Liberation Theology,’ which originated in Latin America contemporaneously with Paolo Freire’s teachings on the Pedagogy of the Oppressed (2017).
Nursologists who plunge into Nursing Ethics, 1880s to the Present will delight in Fowler’s historical exploration about the autonomous praxis of nurses who embody an eminent measure of self-determination and agency. We know deep in our hearts that we actively shape our choices and behaviors through reflections in action and doing. Fowler’s elegant explanation for nursing’s rejection of Cartesian dualism in early nursing ethics illuminates how Nursing did not buy the notion of mind and body as two distinct substances. The National League of Nursing Education (NLNE) was founded to establish a standard nursing curriculum. Despite an “ample body of literature on medical ethics that could have been relied upon to frame or structure nursing ethics content, they [NLNE] intentionally and consciously chose not to use any medical-ethical material per se” (Fowler, 2024, p. 27).
But Fowler also probes the uneasier aspects of Nursing Ethics history: our convoluted relationship with biomedical ethics emerging in the ‘60s, ’70s and ’80s, and a peculiar, stubborn refusal to view that as nurses, we do not objectify our responses to patients entrusting themselves to our care. Fowler dissects the Cartesian mind-body split that occurs in biomedical analysis of ethical dilemmas, chronicles the emergence of bioethics as the dominant paradigm of medicine and health professions, and critically evaluates nursing’s unconsidered acquisition of bioethics.
Fowler shows humility throughout Nursing Ethics, 1880s to the Present, for instance, saluting Patricia Benner, “whose expertise in the domain of nursing practice as a source of ethics far exceeds my own” (p. 246). Calling on her own nuanced grasp of pragmatism, Fowler capitalizes on Benner’s understanding of ‘ethical comportment’ to further elucidate how nurses embody ethical principles in their everyday practice, going beyond ethical dilemma analysis of making and following rules. The nurse instead “focuses on the actions and embodies intentionality of nurses in actual nursing practice,” (p. 288). She goes on to illustrate through stories of caring practices by expert nurses “who responded to nonverbal patients by following the body’s lead, and to the importance of knowing the patient in nursing practice” (p. 288). Fowler portrays the history of nursing ethics through these captivating stories, and analyzes them through droll, chatty observational interludes. Her wit is downright enjoyable, and she provides a final treat of stories in the final chapter, blessing us with the ‘Voices and Vignettes’ of Fowler’s ethics colleagues and friends.
Presently, and in the immediate months and years ahead, Nursologists are challenged to consider our response to women’s compromised reproductive rights, to greater constraints on health care resources, reductions of the nursing workforce from inadequate funding for preparation of nurses; to unjust treatment of immigrants; to an emboldening rise in racism, xenophobia, homophobia, transphobia and lesbophobia. We face antagonism toward our devotion to equity, inclusion, and diversity. We may encounter obstruction to fulfilling our obligations to protect people here and abroad in case of escalating conflict and looming possibilities of war. We need to figure out how to respond to the forces opposing the deepening discovery of our patterns of knowing as we decolonize our ways of knowing. How will we stand up as good nurses and persist in right action?
As we consider this question, let us remember that Fowler explains how our ethical tradition emerged in the Western world. Fowler offers our most optimistic history of Nursing’s fundamental pattern of Ethical Knowing. Nursing Ethics, 1880s to the Present gives us the context for understanding how to be good nurses in the current climate. Fowler beckons us now to renew our ethical tradition, and inspires us to take on and embody the ethics of care and responsibility. She even gives recent examples of contemporary feminists, Black ethicists and Black radical feminist nurses who, with a renewed interest in pragmatism, are challenging the adequacy of analytic philosophy to deal with our most pressing threats.
Nursing Ethics, 1880s to the Present: An Archaeology of Lost Wisdom and Identity was awarded first place in the 2024 AJN Book of the Year Award in History and Public Policy. Let us be inspired to moral courage by likely the most well-timed and important book in nursing of the decade, as we consider how nursing will shape our ethical response to threats to health, vitality, health justice and peace.
References
American Nurses Association. (2015). Code of ethics for nurses. American Nurses Publishing.
American Nurses Association. (2025). Code of ethics for nurses. American Nurses Publishing. https://codeofethics.ana.org/home
Carper B. (1978). Fundamental patterns of knowing in nursing. ANS. Advances in nursing science, 1(1), 13–23. https://doi.org/10.1097/00012272-197810000-00004
Fowler, M. (2015). Guide to nursing’s social policy statement: understanding the profession from social contract to social covenant. American Nurses Association.
Fowler, M.D., (May 31, 2020) “Toward Reclaiming Our Ethical Heritage: Nursing Ethics before Bioethics” OJIN: The Online Journal of Issues in Nursing Vol. 25, No. 2, Manuscript 4.
Fowler, M. (2024). Nursing Ethics, 1880s to the Present: An Archaeology of Lost Wisdom and Identity (1st ed.). Routledge. https://doi.org/10.4324/9781003262107
Freire, P. (2017). Pedagogy of the Oppressed. Penguin Modern Classics.
International Council of Nurses. (2021). The ICN Code of Ethics for Nurses. https://www.icn.ch/sites/default/files/2024-12/ICN_Code-of-Ethics_EN_Web.pdf
About Christina Nyirati
- Member, Advisory Team for Nursology.net
- Retired Professor and Founding Director of the Heritage University BSN Program
- 2023 Nurse Educator Award Recipient from Washington State Nurses Association
- Founding and past Director of the FNP program at The Ohio State University
- Co-founder of “Overdue Reckoning on Racism in Nursing” project with Lucinda Canty and Peggy Chinn.
- Planning team member for the 2025 Virtual Nursology Theory Week
- Collaborator with the Ttáwaxt Project, a movement among Native women on the Yakama reservation, to reduce the high rates of maternal and infant mortality
- IRB member for the Pacific North West University of Health Sciences
- Board member of the Washington Center for Nursing
- Washington State Maternal Mortality Review Panel member.
- Co-author International Family Nursing Association (IFNA) Position Statements on both the Generalist and the Advanced Practice Competencies for Family Nursing Practice
- Nursing praxis is my core. I strive to listen, nurture and work toward peace and health justice in community with others.