Drawn to Feminist Ethics and Its Promise

From Nursing Ethics, 1880s to the Present (p. 382-385)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes

While hard for me to believe, 35 years have passed since my commitment to nursing ethics began. In 1987, I was studying philosophy at York University while working part-time as a nurse at what was then a provincial psychiatric hospital, the Queen Street Mental Health Centre. (This hospital is now part of the Centre for Addiction and Mental Health.) While riding the railway to York one morning, I began to read In a Different Voice by Carol Gilligan,²⁸ which described “women’s” moral orientation. I was immediately struck by how Gilligan’s work resonated with nursing, with its emphasis on care, relationality, and particularly. She contrasted the ethic of care with the ethic of justice, characterizing the latter as being focused on impartiality, duties, and principles in a context of relationships of non-interference. I felt an excitement that there was a perspective that could better inform and articulate nursing ethics than deontology or utilitarianism could. I was now on a mission. During my graduate studies, I continued to explore care ethics but increasingly encountered scholarship that critiqued these perspectives. While care ethics emphasizes the moral imperative of reducing human suffering and maintaining re- lationships, caring relationships have the potential to be exploitative or unfairly partial. Feminist ethicists at that time, such as Claudia Card and Rosemarie Tong, argued that the ethic of care may grow out of and perpetuate “women’s” unrecognized and often exploited caregiving, leading to further powerlessness. In addition, the growing body of empirical research exploring Gilligan’s claims indicated that most people use both care and justice considerations in their moral reasoning.

As a consequence of these critiques, I found myself becoming more drawn to feminist ethics as an approach for nursing ethics. In fact, to this day, I cannot really separate my commitment to feminist ethics from nursing ethics more generally. I initially was drawn to Annette Baier’s work on trust. Her approach combines both love and obligation, which are similar to the ethics of care and justice. From Baier’s perspective, in relationships of love, we trust others not to harm us, and in relationships of obligation, we trust others to recognize and fulfill obligations. Baier’s work was attractive because it is relationship-focused, with the notion of trust implying interdependence.

As a feminist ethicist, I believed Baier’s approach could also help draw awareness of the devaluation and invisibility of nursing, which is partially the result of the practices of nurses being associated with so‑called “women’s work.” My recognition of the lack of esteem given to nurses by the public and health-care professionals, including nurses themselves, and the recognition of the responsibility nurses carry, often without a comparable degree of decision-making power, only further reinforced my commitment to nursing ethics using a feminist lens. Simultaneously, I also came to understand the potential power of nurses in part by reading the work of Sandra Lee Bartky about a feminist consciousness that encompasses a consciousness of both weakness and strength. Feminist ethics as a way of doing ethics helps us question the status quo, making it possible to work toward a better world for all. It is in this potential for change that my commitment to nursing ethics and feminist ethics continues even to this day.

My reflections on ethics and nursing have intensified over the last four years as a result of my responsibilities as the primary caregiver of my sister and parents, all of whom have had serious health problems. I have spent countless hours in hospitals and have done my best to navigate community services, all the while reflecting on love, inevitable losses, aging, the importance of human caregiving, and the potential of nursing ethics. The professional in me has also observed both the strengths and serious shortcomings of the Canadian health‑care system. Most important, however, what used to be more of an intellectual appreciation of the importance of nursing has become a deep emotional appreciation of the significance of nurses’ work and the values that inform it. I have been very lucky until now to have had only a very passing need for nurses, but now I rely on them constantly because of my family’s dependence on them.

It’s absolutely clear to me that nurses have the potential to have an incredible impact on the overall well-being of the lives of people, not only because of their knowledge and skills, but also the values that they enact. The excellent care I have witnessed has often included a deep attentiveness and respect. Yet, upon occasion, I have come across nurses and other health-care professionals who have treated my family members as merely bodies in a bed. It concerns me that only about half of the nurses I have encountered introduce themselves, making it difficult to know who is responsible for care and making nursing less visible than physicians and rehabilitation therapists. This lack of introduction is troubling because of what it signifies. It may mean that nurses consider themselves so insignificant and inter- changeable that they do not think it important to introduce themselves. It may also reflect that the importance of the nurse–patient relationship, often viewed as the foundation of nursing ethics, is only important in theory.

While nurses may go to work believing they are insignificant, they are not. Those nurses who have the capacity to not only be clinically competent but to engage with people with at least some genuine and personalized care are essential. The smallest gesture can be deeply memorable and can help reduce the sense of helplessness in a system that can be depersonalizing for patients, families, and nurses. These encounters make me wonder what accounts for the range of behaviors and approaches. No doubt factors such as excessive workloads and exhaustion could play a role when practice is less than ideal, but there could be more. What role does, or did, ethics as an academic field have on their work? It’s possible that when nursing ethics is taught, we have not adequately described ways in which values can be enacted. The practical application in the everyday likely needs more articulation so that abstract concepts can inspire realistic actions in the context of nurses’ difficult working conditions.

It may also be that some nurses have not developed a robust moral identity as a nurse. Attention to moral identity formation is receiving increased attention in moral philosophy and moral psychology, with moral identity being viewed as the bridge between knowing the right thing to do and acting. I would argue that moral identity also has the potential to give us a sense of power and connection as a group of care providers who have played an important role in hospitals and the community for decades. Nursing ethics can be a part of that moral identity formation, especially if those who teach it and write in the area pay attention to not only the contributions of bioethics, but also those of nursing. We need to recognize that bio- ethics as a discipline has its roots in philosophy, medicine, and law, but that nursing ethics predates this and can offer ways of understanding that can be important to how we view ourselves.

While the historical importance of care and nurse–patient relationships is broadly recognized, Marsha Fowler’s work has also brought to light the lengthy history that nurses have had working toward social reforms to address unjust social structures that lead to health disparities. Nursing ethicists recognize that it is important to embrace a social ethics. Feminist ethics is one approach that can help us be critical of the societies and health-care systems in which we live and work by creating a lens through which we can examine and address the social forces that create disparities and diminish the importance of care. Some of these forces also prevent nurses from delivering care according to their ideals and can lead to exces- sive moral distress.

For example, in Canada there is an extreme shortage of long-term care (LTC) beds not only because there is a lack of physical structures, but also because there is a lack of staff. As a result, hospitalized people who need LTC but cannot access it are what used to be called “bed blockers” because there is nowhere for them to go. While today in Canada the terminology has been sanitized, with these patients now being called “alternative level of care” (ALC) patients, the stigma has not gone away. My mother is such a patient. I have been reminded on several occasions that she is occupying an acute care bed and that I should take her home even though she has had two recent strokes and requires total nursing care. In a strange twist of fate, our family is now living out an extraordinarily distressing set of circumstances that I have written and spoken about many times. Like other family caregivers, if we were to take her home, I would need to leave my paid employment, we would need to renovate a part of our home, hire additional help for the round-the-clock care she requires, and find a way for her to be periodically transported out of the house to see a physician, if we would be lucky enough to find someone who would take her as a patient. No doubt, shifting care to families, especially women, saves the system money, but it is very costly financially and socially for families. With great ambivalence, I am now on the record as “refusing” with everything that implies.

Our situation, in which we are certainly not alone, reflects multiple societal factors that have led to the lack of attention to the LTC and home-care sectors, including the deep-rooted devaluation of care work, sexism, ageism, and neolib- eralism. Because of the disproportionate number of deaths in LTC during the pan- demic, the conditions for those receiving care and working in these settings have become increasingly visible and hopefully, the impetus for change. Nurses need to be cognizant of not only the ethical issues that exist at the bedside, but also those of the broader systems in which they work to be a part of that change. I believe nursing ethics can play a part by providing a lens for the analysis and articulation of the ethical problems that exist not only in LTC, but also in many areas of our health-care systems.

I try to remain hopeful, but critically hopeful, that nursing ethics will maintain a presence in all areas of activity that comprise what we call nursing. Its lengthy history can be the inspiration for the development of the moral identities of nurses. There is realistic hope for the future of nursing ethics because there is an increasingly large cadre of nurses globally with an excellent education in nursing ethics. I look forward to their contributions and how they will leave their marks on the history of nursing ethics.