Marsha Fowler’s Nursology.net posts
Nursing Ethics, 1880s to the Present: An Archaeology of
Lost Wisdom and Identity

The earliest nursing ethics literature began with modern nursing itself.  It was a main ingredient, baked into the cake of nursing, and was not decorative frosting.  It went on to become an extraordinary and extensive body of literature in nursing ethics textbooks, journal articles, and more.  So why, now, is it hard to describe how nursing ethics and bioethics differ in practice?  Nursing ethics is structured on the basis of 6 structural relationships.  It is not based on the four principles of biomedical ethics.  It is clearly relationally based in the structural relationships that are interpersonal.  Throughout it is informed by virtue ethics, and by the philosophy of Pragmatism, an American home- grown philosophy that influenced both American and Canadian nursing.  Bioethics, on the other hand is chiefly influenced by Anglo-European philosophies, grounded in abstract rationalist principles, specifically respect for autonomy, beneficence, nonmaleficence.  But how might the two look different in practice? It is difficult to find a single clinical case that exemplifies the difference between bioethics and nursing ethics.  However, enter Netflix, with a case that does.

I unexpectedly happened upon a TV movie, My Oxford Year, and started to watch it because, well, it’s Oxford – a wonderful city and amazing architecture, a wonderful university, and of course it has the scholar’s heaven—the Bodleian Library.  It is not a great movie and follows a standard romance-movie plot. However the later half of the movie demonstrates a difference between how bioethics and nursing ethics function (at 1 hour 5 minutes into the movie – you can start here if you wish to skip the gorgeous Oxfordian scenery).

The Story

An American girl (Anna) graduates with a degree in English and has a job offer as a financial analyst for Goldman Sachs (a curious combination – English literature and financial analysis?).  The job is to follow a year studying Victorian Poetry at Oxford with Prof. Stein. Girl meets obnoxious and attractive boy (Jamie) when he, a DPhil dissertation student, is unexpectedly assigned to teach Dr. Stein’s Victorian Poetry course. They get off on the wrong foot and snipe and snark at one another, slowly falling in love over 15 minutes. Jamie is now Anna’s tutor (instructor) and a ”serious piece of crumpet,” and has a scheduled meeting with Anna in his “rooms” (office).  She shows up and sees him arguing angrily with an older man (later revealed to be his father). The relationship between Jamie and Anna heats up, but at one point she thinks he is two-timing her.  She goes to his apartment (she now has the combination to the door) and walks in only to find him hooked up to IVs and with an attractive woman whom she had previously wrongly thought his girlfriend.  Enraged, he screams at her to get out; Anna leaves.  Several days later, he discloses that his brother died of an unspecified, rare, incurable, untreatable, genetic illness, and that it was a slow painful death that undid their father.  And Jamie has the same disease.  His father wants him to “fight to the end.” Jamie tells Anna that the IVs she saw were the last treatment he would accept, but his father can’t “respect that choice.”  Father and both sons had been close and shared a love of assembling model cars together. Since the death of Eddie, Jamie’s brother, father and son are angrily estranged and are not speaking. When Anna and Jamie meet his parents at a ball, Jamie gives his father the cold shoulder. The father takes Anna aside and asks her to convince Jamie to accept treatment.

Jamie’s parents, the likable Lord and Lady Davenport live in a monstrously large manor, palatial but not a palace, where Jamie throws a birthday party for Anna, inviting her four  flat-mates. Before dinner, Jamie goes to the wine cellar (1h 18m) to fetch another bottle and encounters his father. His father is grief-stricken at Jamie’s decision, and he tries to explain to Jamie what it means to lose two sons to this disease and that Jamie needs to keep fighting and “Please, I am just trying to keep you alive.” Jamie responds “It’s not your decision to make.”  Yup, there you have it.  The bioethicists in the other wing of the manor are huddled, it is an easy question, inviolable principle of respect for autonomy, Jamie has decided, no discussion needed; done and dusted.

But wait, Anna the poet, who should have been a nurse (okay, she’s not a nurse, but nursing is  poetic on its own) is distressed by the rupture in the father-son relationship and wants to see it healed for both their sakes. She is outside with Jamie and excuses herself; she has something to do.  Next we see her giving a gift to Jamie’s father, with a card.  The card is inscribed with words of the poet John Keats: “Stop and consider//life is but a day//A fragile dew-day on//its perilous way.” The father opens the package and it is a model car kit, the Jaguar-E that Jamie drives.  Later, as Jamie and his father assemble the car together (1hr 24m in), their freeze thaws, and the father tearfully agrees to Jamie’s wishes.  At dinner the father stands and toasts Anna as she has “brought together Keats, cars, and Eddie to make this evening happen” — to heal the breach between father and son (1h 29m).  Days later, when Jamie collapses and is in hospital, the physician says that they need to start treatment now.  Jamie’s father says “No, that’s up to Jamie and he would prefer to let nature take its course, and we should respect that.”

Seeing a Difference between Bioethics and Nursing Ethics

With only simple descriptions, it is hard to visualize how bioethics and nursing ethics function differently in clinical cases. This film provides a useful vehicle. Nurse poet Anna had brought together Keats, cars, Eddie, father, and son, in a way that respects the health and healing needs of both father and son, within its relational nexus: ethics as relationship. She dealt with the father’s grief in a way that affirmed both Jamie and his father. This was not decisional ethics based on parsing an abstract principle of respect for autonomy.  Instead, Anna was responsive and attuned to their history, love, grief, needs, and wishes, of both father and son, and brought them together wholistically to enact an ethics of relationship.

Nursing ethics is a hundred years older that bioethics. 

Nursing ethics brings clinical-ethical wisdom to nursing, grounded in generations of nursing experience, and the community and tradition of nursing’s normative values. It is not a dilemma based, decisional ethics, based on abstract principles, though the principles can be synergistic in the practice setting. Nursing ethics was promulgated by-nurses-for-nurses; grounded in the values and virtues of the community and tradition of nursing; rooted in nursing practice, and responsive to it (see Nursing Ethics, 1880s to the Present) . Interpersonally, as an ethics of relationship it is relationally structured. Additionally it exercises ethics in practice in ways that are widely responsive to health-related needs, in ways that are attentive, situationally attuned, affirming of relationships, and demonstrate relational moral comportment.