Heritage ethics

Introduction

The argument continues as to whether there is a distinctive nursing ethics, or whether nursing ethics is a variant form of medical ethics, or whether it is a subset of biomedical ethics, or a subset of bioethics. Opinions diverge and some choose a position often without offering an apologetic for that position. However, these arguments all suffer from the same failings. First, they argue from a post-1960s perspective when the rise in biomedical ethics ensued, so they set the argument about nursing’s ethics within a historically disconnected context. As much as some argue against ethical principalism as a priori and divorced from the historicosocial context, even those who argue for a care-based relational ethics fall into this trap when arguing for a distinctive nursing ethics rooted in caring. Were there a greater corpus of research on nursing’s ethical history it would decidedly recondition the entire argument about a distinctive nursing ethics. There is a distinctive nursing ethics, but one that falls outside both biomedical and bioethics and is larger than either. Historically in the United States, nursing’s ethics has borne a much stronger tie to social ethics than to the later developed and narrower bioethics, a tie that still binds. This tie can be seen in a number of references that follow and evidences contemporary nursing’s century of contiguity with social ethics. However, the purpose of this work is less apologetic in nature than it is donative in seeking to give to nurse scholars access to documents and sources to which they might not otherwise have access. The practice of nursing is deeply characterized by a donative element, a gift element. Patients give themselves into the care of nurses, trusting their lives and well-being to a stranger’s hands. It is the donative element of the nurse–patient relationship that more generously situates that relationship as covenantal, beyond the contractual. ¹ The donative element also remains an element within caring ethics that is largely unexplored. Yet, the nurses who have gone before this generation, who have given of themselves and their lives both to improve patient care and to advance the profession itself so that nurses, patients, and societies may benefit have also participated in the gift element of nursing. The purpose of this work is to “re-gift” what they have given nursing ethics. This work, then, is intended to provide easier access to source data for a historicocritical perspective on nursing ethics to the end of developing a thicker account of nursing ethics, one that points toward nursing ethics as always both patient-centered and socially concerned.

The resources discussed below are from the early US nursing literature, although some may have been used in the United Kingdom as well. The nature and content of these resources have been analyzed elsewhere. ² They are identified and brought together here as a beginning compendium of historic nursing ethics sources that provide a fuller account of nursing’s ethics than does the epithet “bioethics.” It is hoped that this will be enabling for those who wish to pursue and develop this domain of inquiry, and that it will spur nurses to gather similar such ethics resources for their own nations and cultures.

Early US books on ethics in nursing

In 1965, the American Nurses Association (ANA) published a position statement that called for the movement of nursing education into institutions of higher education (colleges and universities). Within less than a decade, this position led to the rapid closure of most of the hospital-based schools of nursing in the United States, some of which, at that time, had been in operation for almost 100 years. Their closure led to the dispersal of their libraries with a consequent loss of extremely valuable resources for nursing ethics history. The growth of the Internet has made some of those historic books newly available from used book sellers, although identifying historically pivotal nursing textbooks still depends, to some extent, on having an author and title. Between the 1890s and the 1960s, approximately 50 textbooks on ethics in nursing were published. That list is included here (see Appendix 1) for those who wish to pursue a longitudinal analysis of content. The majority of these works were authored by nurses, but some were written by social workers, physicians, and priests. A few were written for both medical and nursing students. The books by Robb and Aikens remained in print for decades, and Aikens’s book went through several editions. While these have been analyzed in some depth elsewhere, a few amuse-bouche are offered here.

Confidentiality (termed “professional secrets”) was one of the earliest, most stringent, and persistent ethical norms for nurses. It is mentioned in the Florence Nightingale Pledge, written by Lystra Gretter in 1893, ³ as well as in all of the early nursing ethics textbooks. Early post-graduate nursing in the United States (largely through World War II (WWII)) took place in the home where nurses could observe the machinations of family life. Confidentiality was as much or perhaps more tied to what the nurse knew about the family (or husband) than specifically to information about the patient. Concerns for privacy do not emerge in the United States until privacy becomes a public and social issue in the law, but a norm of confidentiality greatly predates the emergence of the field of bioethics.

Nursing, concerned about its social status as a profession, mimics the “classic professions” of law and medicine in proscribing advertising. This proscription appears in the first adopted codes of ethics. When challenged, it is defended as a means of protecting the patient from self-medication and quackery. However, nursing had failed to examine the origins of anti-advertising norms. They are actually based in attempts in the 1800s to prevent fee wars among lawyers and physicians that would drive down fees and thus reduce potential income. This prohibition was pristinated by medicine as a means of preventing self-medication and quackery in the days of patent medicines. ²

Early nursing ethics in the United States was focused on an ethics of virtue, particularly “womanly virtue” (see Appendix 2). Considerable attention is paid to character and its manifestations, to the degree that this is sometimes misconstrued as “etiquette” instead of ethics. Nursing does not shift to a duty-based ethics until about a decade after society makes that shift—or until nursing shifts into colleges and universities. Virtue ethics flourished in the sequestered environment of hospital schools of nursing. In addition, personal and professional or private and public ethics were seen as indivisible: one was in public life what one was in private life.

Nursing’s official position on acceptance of patients no matter their “race, creed, nationality” had been substantially ahead of its day and predated the US Civil Rights Movement. What begins as a proscription against prejudicial behavior on the basis of race, creed, and nationality across the decades expands in the nursing ethics literature (and Code of Ethics) to include religious beliefs, color, status, country, ethnic identification, beliefs, living conditions, customs, attitudes, and economic status and today includes culture, life stage, socioeconomic status, personal attributes, nature of the health problem, age, sex, personality, background; political, educational, economic, developmental, personality, role and sexual differences; value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language.

Journal articles

The Trained Nurse and Hospital Review (also The Trained Nurse) was the first true nursing journal in the United States. Its volume 2 contained a six-part series of articles on nursing ethics, divided on the basis of seven “classes” of nursing relationships:

For convenience sake, I will divide the duties of a nurse into seven classes: 1^st. Those she owes to the family. 2^nd. Those she owes to the doctor. 3^rd. Those owing the family, friends, and servants of the patient. 4^th. To herself. 5^th. To her own friends. 6^th. To her own hospital or school. 7^th. To other nurses. ^{4 i}

The American Journal of Nursing (AJN), begun in 1900, published over 400 articles principally on nursing ethics between 1900 and 1965. ² An important feature of these articles, that remains to receive the research attention that it deserves, is that of shifts in language. There is a general shift from the language of virtue to duty as well as an increasingly more ethically informed use of ethics language and categories across the century that needs to be examined. However, it should be noted that a number of nurses who wrote about ethics availed themselves heavily of the assistance of professionally educated ethicists, philosophers, and theologians; although written largely for a student readership, these early works are neither ethically naive nor primitive. The ways in which changes in ethical language shape and reshape the conceptualization of nursing ethics are an important domain in need of study. Early nursing ethics articles might run under a title “talks to nurses” or “the art of conduct.” In addition, while early nursing ethics refers to ethical concerns as moral or ethical issues in the 1930s and 1940s, they are renamed professional problems or professional adjustments in nursing, perhaps referencing nursing aspirations toward being socially regarded a profession. That language is dropped by the 1950s. In addition, there is a similar language shift in the titles of the various ANA codes of ethics from “Code for Nurses,” “Code for Professional Nurses,” to “Code of Ethics for Nurses.” Because of language changes, searches for journal articles on nursing ethics must track and include terms that are not overtly ethical in content and that obscure the ethical nature of the writings.

The first research in nursing ethics and early dissertations or theses

The US journal Nursing Research did not begin until 1952. For research on nursing ethics prior to that year, it is necessary to search dissertations and theses. The first extant example of research in nursing ethics is that conducted by Sr Rose Hélenè Vaughn who completed a “dissertation” (thesis) for the Master of Arts degree at The Catholic University of America. The dissertation was entitled The Actual Incidence of Moral Problems in Nursing: A Preliminary Study in Empirical Ethics. ⁵ The purpose of her study 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 asked nurses to keep diaries. A total of 173 nurses agreed to do so. In all, 95 nurses returned 288 diaries. She culled 2265 ethical incidents from those diaries, which she categorized into 33 categories. The results indicated that the clinical-moral problem most frequently encountered by nurses was that of cooperation between nurses and physicians. Many of the moral problems that Vaughn identified in 1935 persist in nursing today. A case in point is her category “lust” (6th of the 33 categories listed by frequency) that includes a number of incidents that today would be called “sexual harassment.”

For data on nursing ethics, it is also useful to search dissertations and theses on nursing history that may or may not be written by nurses. Dissertations and early works on nursing history, as well as early feminist works that reference nursing, often contain important information, directly or indirectly, about nursing ethics. As importantly, they contain social contextual information that looks at forces that shape nursing and likely influence behavioral standards and expectations, character attributes that are preferred or sought, or ethics specifically. To that end, particular note should be made of the works of Ashley, ⁶ Dock, ⁷ Ehrenreich and English, ⁸ Melosh, ⁹ Sheahan, ¹⁰ and Stewart. ¹¹ It is also important to examine those works within the context of contemporary feminist, race, capabilities, postcolonial, and other critical and intersectional theories to examine the ways in which professional ethics and aspirations are socioculturally interactive and informed.

Accreditation and regulatory boards: curricular content in ethics

The minutes and documents of an accrediting or regulatory body may contain the curricular requirements for ethics in nursing curricula and can be a useful source of data. In the United States, the nursing school accrediting body was originally the National League for Nursing Education (NLNE) (later the National League for Nursing). Each state had its own “nurse practice act” that was overseen by a State Board of Nursing, which also regulated nursing education.

In 1917, the NLNE published its “Standard Curriculum for Schools of Nursing.” It required 10 hours lecture on ethics in the second year (the same number of hours allotted to other major topics). The basic ethics lectures were mandated to include major sections on the following:

Introduction: Customary Morality;

These requirements extend to social concerns. Nursing students received additional ethics-related lectures on “Social and Professional Subjects” that included “ethical and social principles” in the history of nursing, and “modern social problems.” ¹² Additional ethics content was included under the subject area of “Psychology and Problems of Professional Life.” Ethical considerations were also woven throughout clinical course work.

The 1916 Bureau of Registration of Nurses, California State Board of Health, curriculum requirements for ethics for schools of nursing were substantial. No other subject matter receives more attention than does ethics, and it equaled only “Materia Medica” (today called medical-surgical nursing). A course in ethics was required 5 out of 6 semesters of the curriculum. Requirements included mandated lectures and extensive readings on “Democracy and Social Ethics,” “Modern Industry,” “Housing Reform,” “The Spirit of Youth and the City Streets,” and other social-ethical concerns. ¹³

These early requirements mandate content in social ethics. This effectively removes nursing’s ethics from the realm of a “bedside ethics” alone to one that reaches into both the problems of society and the structure of society. These early requirements are the precursors to contemporary nursing’s ethics concern for health disparities. However, an examination of these historical requirements in social-ethical and social justice content, as well as the nursing ethics historical literature, indicates that nursing’s perspectives on social justice do not align very well with the bioethical discourse on distributive justice and are far closer in spirit to the contemporary work by Baier, ¹⁴ Held, ¹⁵ Kittay and colleagues, ^16,17 Mills, ¹⁸ Nussbaum, ^{19 –21} Pateman, ^{22 –25} Tronto, ²⁶ and others who look closely at social structural inequities far more broadly than concerns for the costs of and access to healthcare.

Organizational committee minutes

The ANA, established in 1896, has kept records and minutes of its workings, including committee work, as has the NLNE. In 1921, the NLNE appointed an advisory Committee on Ethical Standards. The committee studied the need for a code of ethics for the profession. Their conclusion was that “… nurses throughout the country are desiring something concrete which they may accept as a basis for professional conduct.” The committee formally recommended to the parent body the preparation of a “statement of the principles of nursing ethics.” ²⁷ The NLNE received the report and approved its recommendations. However, at a 1923 meeting of the joint boards of the NLNE and the ANA, Adda Eldredge (then ANA president) requested that the committee become a part of the ANA rather than the NLNE. The reason given was that the ANA ²⁸ “had planned to compile a code of ethics as a part of the Association’s work” as had been declared in its 1896 articles of incorporation. The NLNE agreed, and the task of formulating a code of ethics for the profession thus shifts to the ANA. The bulk of this information is found in the minutes of the committees of both organizations.

The minutes of the founding meeting of the ANA includes its articles of incorporation which state, in part,

The object of the Association shall be: To establish and maintain a code of ethics, to the end that the standard of nursing education be elevated; the usefulness, honour, and interests of the nursing profession be promoted, public opinion in regard to duties, responsibilities, and requirements of nurses be enlightened; emulation and concert of action in the profession be stimulated; professional loyalty be fostered, and friendly intercourse between nurses be facilitated. ²⁹

The minutes of the committees make for interesting reading although they often obscure debate on issues under the rubric of “discussion.” These minutes are at risk of being lost forever. They were often typed on a manual typewriter with “carbon copies.” The heavy keystroke necessitated by making carbon copies often pierced the paper itself and also left the bottom copies faint. The minutes were typed on non-acid-free paper. Sometimes the minutes were “mimeographed” with a blue ink that faded with exposure to light. These minutes have never been digitized in order to be preserved.

Codes of nursing ethics

There are several US codes of ethics—and one oath or pledge. In 1873, Lystra Gretter composed an oath, patterned after the Hippocratic Oath of physicians, to be administered at nursing school graduation ceremonies. She honorifically named it the Florence Nightingale Pledge (the Pledge). The original and widely accessible version of the Pledge was as follows:

I solemnly pledge myself before God and in the presence of this assembly:

To pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.

I will do all in my power to elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping, and all family affairs coming to my knowledge in the practice of my profession.

With loyalty will endeavour to aid the physician in his work and devote myself to the welfare of those committed to my care. ^{33 ii}

Eventually, the Nightingale Pledge, which was widely administered to graduating classes in the United States (and is still in use), was followed by a formally adopted ANA code of ethics. As noted above, the first two draft codes were not accepted. The first code to be formally adopted by the Association was the code of 1950. There have been subsequent revisions of the code and the addition of interpretive statements. Here is the timeline for those code revisions:

1893—The “Nightingale Pledge,” patterned after medicine’s Hippocratic Oath, is commonly viewed as the first nursing code of ethics in the United States.

An analysis of these codes and their interaction with the social milieu of their day can be found in several sources. ^2,35 Over the course of successive revisions, interpretive statements were added. Initially, “the code” was the provisions only and the interpretive statements were explanatory and descriptive. By 2015, the interpretive statements became interpretive and normative. Thus, today, “the Code” is both the provisions and the interpretive statements.

Personal Stationary: Letterheads

Personal stationary can provide additional, indirect, information. For example, the extensive British and American holdings of the Huntington Library (San Marino, California) include a meager number of letters written by prominent nurses in the late 1800s and early 1900s. The content of these letters is of little import. However, these nurses used a surprising range of letterheads in their personal communications. The greatest number of letters was written on Red Cross letterhead. However, the letterheads also included the American Society for the Prevention of Cruelty to Animals, the Antivivisectionist League, the Vaccination League, and more, all related to social causes. What is important here is that these nurses were involved in social causes that were not written about in the nursing journals. It is necessary to look beyond the journals to see the extent of nursing involvement in issues of social justice. There is no nursing research in this domain of data.

Conclusion

It is hoped that this brief article will accomplish several ends. The first and simplest is to call attention to the existence and importance of historical resources in nursing ethics that are disappearing. The second, like unto it, is to prompt the collection of such resources across cultures and nations in order to create and preserve a global bibliographic body of nursing ethics’ historical resources. The third is to preliminarily call attention to gaping holes in the research on nursing’s ethical tradition. More importantly, however, an analysis of nursing’s ethical tradition over the past century and a half is essential to challenging contemporary bioethics as a derailment of nursing ethical tradition and identity, and a medical colonization of nursing’s ethics that creates a discontinuity with nursing’s ethical history. It also challenges the notion that nursing’s ethics is simply bioethics or biomedical ethics (in part or at all) when its history would instead place it within the broader sphere of social ethics. Nursing stands in need of a thicker account of its ethics.