Human rights and nursing codes of ethics in Canada 1953–2017

Introduction

Human rights are foundational to the health and well-being of all individuals nationally and globally. According to the United Nations Declaration of Human Rights, human rights recognize ‘the inherent dignity and…the equal and inalienable rights of all members of the human family’ (p. 1). ¹ Throughout history, human rights have often been considered central to the profession as illustrated through nursing scholarship, organizational statements and ethical codes. ^{2 –4} Codes of ethics in the Canadian, American and international nursing context formally began in 1950 and have remained a key policy document for the nursing profession within these jurisdictions. ⁵ To date, the Canadian Nurses Association (CNA) has adopted nine different codes of ethics with two being adopted from the International Council of Nurses (ICN) in the early years (Table 1). In Canada, the purpose of the nursing code of ethics can be understood as ‘a statement of the ethical values of nurses and of nurses’ commitments to persons with healthcare needs and persons receiving care. The code is both aspirational and regulatory’ (p. 2). ⁶

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Table 1.

Codes of ethics referenced.

Year	Developed by:	Adopted by:
1949	World Medical Association (WMA)	WMA – London, England; recognized by World Health Organization (WHO) – Geneva, Switzerland
1950	American Nurses Association (ANA)	ANA
1953	International Council of Nurses (ICN)	ICN – San Paulo, Brazil; Canadian Nurses Association (CNA) – Banff, Canada (1954)
1965	ICN	ICN – Frankfurt, Germany; CNA – Montreal, Quebec (1966)
1968	WMA	WMA – Sydney, Australia
1980	CNA	CNA
1985	CNA	CNA
1991	CNA	CNA
1997	CNA	CNA
2002	CNA	CNA
2008	CNA	CNA
2017	CNA	CNA

Method

Examining key historical policy, such as codes of ethics, is essential to understanding continuity and change in how human rights are taken up within the profession. D’Antonio and Fairman ⁷ contend that nursing history ‘provides a critically important perspective if we are to understand and address contemporary health system problems’ (p. 113). This article uses the historical method outlined by Lewenson and McAllister ⁸ to compare the nine ethical codes of CNA with a focus on how human rights are positioned. Lewenson and McAllister ⁸ outline a six-step historical method process: identify an area of interest, propose questions, formulate a title, review the literature, interpret data, and tell the story (p. 7).

Our interest in studying nursing codes of ethics was to expand the Canadian nursing consciousness regarding the history of human rights in nursing policy and about contemporary Indigenous rights. A wide range of historical and recent literature was reviewed to support a robust understanding of the context surrounding the development of the codes. Primary data sources were difficult to locate because only contemporary codes are available on the CNA website. Nursing history books, online code of ethics repositories and Internet search engines were utilized to locate each Canadian code spanning the last six decades. Primary sources were reviewed for continuity and changes over time with specific attention to comparing and contrasting human rights language. Furthermore, this article explores how nursing policy, political influences and changes within the profession have influenced the authority of nursing’s code of ethics and its ability to support nurses in carrying out ethical obligations specific to human rights. We contend that the authority of Canadian nursing codes of ethics to uphold human rights within the profession and nursing practice has diminished over time. Finally, we discuss the impact of these changes concerning the protection of human rights in today’s healthcare landscape and the implications for nursing’s ethical obligations.

Canada and the ICN

Integral to understanding the context in which the Canadian codes were developed and adopted is the historical and present-day relationship with the ICN. In 1899, led by suffragist and founder of the British Nurses’ Association, Ethel Bedford Fenwick, the first international organization uniting any health profession was founded – the ICN. ^{9 –11} Born in the context of first-wave feminism, the objectives of ICN were threefold: supporting (1) the interests of women, (2) the welfare of nurses and (3) the health of the public. ⁹

Sometimes called the ‘Florence Nightingale of Canadian Nursing’, Mary Agnes Snively led the development of the CNA in 1908, noting that to be a member of ICN, Canada required a national organization. ^10,12 Snively was well-connected in the early development of the ICN and served as the first honorary treasurer of ICN. ¹² Today, the CNA continues to represent more than 148,000 Canadian registered nurses nationally and internationally. ¹³ Similarly, the ICN’s membership now represents more than 130 national nursing organizations, growing from just 60 organizations in the late 1960s. ^12,14

The relationship between CNA and ICN has continued being ‘active, steady and contributive’ and has included the election of several Canadian presidents, vice presidents and board members alongside hosting the international congress three times in Montreal in 1929 and 1969 and in Vancouver in 1997, and Montreal will host the 2023 congress. ^12,15,16 One key aspect of the relationship between CNA and ICN, in the early days of both organizations and today, is that CNA has looked to ICN as the global body of nursing policy for nursing practice, regulation and welfare. ¹⁷ This includes position and resolution statements, practice standards and codes of ethics.

The early years: code of ethics (1949–1965)

The historical roots of nursing are deeply grounded in ethics, and it remains a central tenet of the profession to this day. ¹⁸ Since the inception of the first professional nursing associations in the late 1800s, discussions and attempts to write an official nursing code were prioritized; however, as nurses struggled to articulate the ontology of the discipline, consensus proved challenging. ¹⁹ The development of ICN’s first code of ethics was prompted by the 1949 Executive Board of the World Health Organization (WHO) who became aware of the work of the World Medical Association (WMA) to create an ‘international code of deontology in connection with the practice of the profession of medicine’ (p. 168). ²⁰ Being one of only seven non-governmental organizations that held official relations with WHO at its conception in 1948, ICN was notified of WMA’s work. ^20,21 The WMA code of ethics was adopted that same year and shared with ICN. ^20,22

In 1953, ICN developed and adopted its first code of ethics. ²³ This brief document outlined fourteen statements articulating the obligations that professional nurses are bound by, not only in their nursing practice but also in their personal lives. ²³ With The Universal Declaration of Human Rights (UDHR) adopted by United Nations member states just six years before the development of this first code of ethics, language and statements within the policy reflect some perspectives that uphold tenets of equality that were the foundation of the very development of the United Nations in the post–World War II period. ^1,24 The 1953 code includes a preamble to the fourteen obligations articulating that the code is grounded in the belief ‘that the nurse believes in essential freedoms of mankind’ (p. 2). ²³ In addition, the preamble outlines that the code affirms that ‘professional nursing service is, therefore, unrestricted by considerations of nationality, race, creed, colour, politics, or social status’ (p. 2). ²³ This statement also mirrors that of the Declaration of Geneva, a policy adopted by the WMA in 1948 and referenced in 1949 WMA’s code of ethics; it states, ‘I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient’; (p. 1). ²² Aside from the WMA policy naming race only, not race, creed and colour, the statements are considerably similar.

In 1965, a second edition of the ICN code of ethics was adopted in Frankfurt, Germany. ²⁰ This revised version was nearly identical to the 1953 code – aside from one major addition. This major addition referenced a significant international humanitarian law (IHL) of the time: ‘It is important that all nurses be aware of the Red Cross Principles and their rights and obligations under the terms of the Geneva Conventions of 1949’. ^20,25 The 1949 Geneva Conventions reflect IHL or the ‘laws of war’; however, IHL and human rights law are ‘complementary bodies of law’ (para. 1). ^25,26 In addition, IHL and human rights law are ‘both concerned with the protection of life, health and dignity’ and differ only in that ‘IHL applied in armed conflict while human rights law applies at all times, in peace and war’ (para. 1). ²⁶ In 1968, the WMA also published the second edition of their code of ethics. ²⁷ The minute changes from the first code did not, however, include the reference to the Geneva Conventions of 1949 as ICN’s did. ^20,27 This language demonstrates a certain ethical impetus for the nursing profession in prioritizing the international conventions that uphold human rights during times of conflict. This was motivated in part by the notable involvement of nurses during war and conflict throughout history, including both World War I and World War II. ²⁸

In 1950, three years before the first ICN code of ethics, and two years after UDHR was adopted, the very first formal nursing code of ethics, the Code for Professional Nurses, was developed and adopted by the American Nurses Association (ANA). ²⁹ The ANA code of ethics was very similar in structure and content to the 1953 ICN code in being a single page with a preamble and outlining obligations for ethical professional nursing. ^23,29 However, some noteworthy differences remain, despite references to the policies being ‘almost identical’ (p. 31). ¹⁹ In 1952, the ANA published an article in The American Journal of Nursing that clarified and expanded upon their 1950 code, citing the possibility of misinterpretation due to its brevity and to answer any questions. ²⁹ In the preamble of the 1950 ANA code, it reads that ‘inherent in the code is the fundamental concept that the nurse subscribes to the democratic values to which our country is committed’ (p. 1247). ²⁹ This statement further describes that the democratic values being referenced are:

…so clear cut that we must choose between two alternatives: We either believe in the intrinsic dignity and worth of each human being and accepting the implications of that; or we agree that human beings have neither dignity nor worth, and may there justly become the chattels or some other human beings who become powerful enough to force them into slavery. (p. 1247) ²⁹

One contention for the differences between these codes could be reflective of the different jurisdictional reach between ANA and ICN; however, notably within the Canadian context, CNA adopted the 1953 ICN code of ethics in 1955 and the 1965 code of ethics in 1966 as the official codes for nurses in Canada, and not the ANA code. ^6,12,19 This international adoption is particularly interesting because before the establishment of ICN, CNA or ANA, The Nurses’ Associated Alumnae of the United States and Canada was founded and represented both Canadian and American nurses; Isabel Adams Hampton, a Canadian nurse, was the first president of this organization. ¹⁰

CNA’s first developed codes of ethics (1979–1991)

While evolving to include more social factors, the language used to outline a nurse’s ethical obligation to human rights weakened despite the immense developments in human rights policy during this period. The developments listed below are in addition to the 1948 UDHR, the 1948 Convention on the Prevention and Punishment of Genocide and the 1949 Geneva Conventions, all of which the Government of Canada was a signatory of (albeit not without significant pressure) and the ICN supported. ^{30 –32} Between the 1940s and late 1990s, there were significant developments in international human rights and humanitarian law treaties. This includes seven of nine human rights instruments (consisting of expert committees that monitor the uptake of these treaties) still used today: ³²

1965 – ICERD (International Convention on the Elimination of All Forms of Racial Discrimination);

In 1978, Sister Simone Roach was selected to lead the development of CNA’s first code of ethics developed by their organization because of her ‘scholarly, spiritual and principled thinking’ (p. 284). ^10,33 CNA having previously adopted the 1953 and 1965 ICN codes, this new code was vastly different in structure and content to its predecessor. The 1980 code tripled in length and focuses on the concept of caring as the basis of the discipline of nursing. ^34,35 This is likely due to the focus of Sister Simone’s ‘theoretical and practical work in the areas of care, caring, and nursing ethics’ (p. 283). ³³ This first code of ethics developed by CNA departs from the language in the earlier 1965 ICN and 1950 ANA codes in their inclusion of IHL and national conventions as ethical obligations for nurses. However, even after many decades, the 1980 CNA code of ethics includes nearly identical language to the 1953 ICN, 1965 ICN and 1950 ANA codes, in contending that ‘The human person, regardless of race, creed, colour, social class, or health status, is of incalculable worth, and commands reverence and respect’ (para. 20). ³⁴ This statement is listed under the ‘General Principles’, not under the ‘Statements of Ethical Responsibility’ section (para. 21). ³⁴ By removing this statement from the section that outlines what nurses are ethically responsible for into general principles, the weight of this statement becomes discretionary as a general principle that guides the ethical responsibilities of nurses.

In 1985, CNA adopted its fourth official policy on ethical nursing obligations (revised in 1991), and the second developed by CNA. ^6,36 Similar to the significant change in these policies between 1954 and 1980, the 1991 CNA code of ethics is considerably different from just five years before. ³⁶ The 1991 CNA code is split up into thirteen values, and each includes a description, obligations and limitations. ³⁶ This substantial change in the code parallels the shifting nature of nursing from an apprenticeship model to postsecondary education and the ensuing ‘professionalization of nursing’. ³⁷

In a nearly identical manner to the 1950 ANA code, the 1953 and 1965 ICN codes, and the 1980 CNA code, the 1991 policy states that ‘Factors such as the client’s race, religion or absence thereof, ethnic origin, social or marital status, sex or sexual orientation, age, or health status must not be permitted to compromise the nurse’s commitment to that client’s care’ (para. 16). ³⁶ The 1991 statement compared to the 1980 statement includes many additions such as absence of religion, ethnic origin, marital status, sex or sexual orientation, age or health status. ³⁶ Also different from the 1980 code, this statement is included under the heading of ethical obligations ‘Value I: Respect for Needs and Values of Clients’ described as ‘A nurse treats clients with respect for the needs and values of clients’ (para. 16). ³⁶

The change over time between these policies may seem minimal; however, it is noteworthy to recognize the minor changes in language that influence the ethical obligations of an entire profession. In the 1953 ICN code, nursing’s ethical obligation was ‘unrestricted’ by the listed sociopolitical factors (p. 2); ²³ in 1980, CNA’s code articulates that people ‘command reverence and respect’ (p. 3); ³⁴ in 1991, these factors must not ‘compromise the nurse’s commitment to that client’s care’ (para. 17). ³⁶

Recent history (1997–2002)

In 1997, CNA adopted its third edition of a Canadian developed code of ethics. ³⁸ Similar to the 1991 code, this policy is organized based on seven values that are said to be ‘central to ethical nursing practice’ (p. 66). ³⁸ One reference to human rights, similar to the previous iterations, appears under the value of ‘fairness’ defined as ‘principles of equity and fairness to assist clients in receiving unbiased treatment and a share of health services and sources proportionate to their needs’ (p. 67). ³⁸ This statement outlines that:

Nurses provide care in response to need regardless of such factors as race, ethnicity, culture, spiritual beliefs, social or marital status, gender, sexual orientation, age, health status, lifestyle or the physical attributes of the client. (p. 70) ³⁸

The 2002 version had minimal changes compared to the 1997 iteration except for one major shift; it included the first conceptualization of justice which replaced the category for value of fairness and would now become the home for ethical responsibilities regarding human rights. ^39,40 We recognize that social justice and human rights are not identical concepts, yet we intend to highlight the change to include social justice within contemporary codes. We contend that the relationship between both social justice and nursing ethics, and human rights and nursing ethics is targeting the root causes of health disparities, namely, systemic marginalization or discrimination stemming from any number of intersecting factors. This fourth iteration was organized into eight values. The statement pertaining to human rights, similar to prior documents, is situated under the ‘Justice’ value, citing that ‘Nurses must not discriminate in the provision of nursing care based on a person’s race, ethnicity, culture, spiritual beliefs, social or marital status, sex, sexual orientation, age, health status, lifestyle, mental or physical disability and/or ability to pay’ (para. 33). ⁴⁰ Added factors to this list included mental or physical disability and ability to pay. ⁴⁰ This shift in language towards justice was a significant change that reflected the philosophical shifts of the times from an ideology of equality to one of equity that remains current to present-day practice. Nevertheless, Kikuchi ³⁹ criticizes that the 2002 version’s first attempt at incorporating justice was inadequate and most notably did not define human rights, and the resulting ambiguity gave little ethical decision-making power for nurses.

The 2002 code also reflects stronger language in response to the imperative of nurses to not ‘discriminate’, rather than the ‘response to need regardless of…’ (1997), must not ‘compromise the nurse’s commitment to that client’s care’ (1991), ‘unrestricted’ (1991), that people ‘command reverence and respect’ (1980) and being ‘unrestricted’ by the listed sociopolitical factor (1953 and 1965). Under the same value, the last ethical statement mentions the first reference to social justice in CNA-adopted codes, stating:

Nurses should be aware of broader health concerns such as…violations of human rights…and are encouraged to the extent possible in their personal circumstances to work individually as citizens or collectively for policies and procedures to bring about social change, keeping in mind the needs of future generations (ANA, 2001). (Para. 33) ⁴⁰

The 2008 code offered little change concerning how to define justice but included explicit reference to human rights by citing the definition and how it relates to the concept of justice. ⁴³ The 2008 code defined human rights as:

the rights of people as expressed in the Canadian Charter of Rights and Freedoms (1982) and the United Nations Universal Declaration of Human Rights (1948), and as recorded in the CNA position statement Registered Nurses and Human Rights (CNA, 2004a). (p. 25) ⁴³

Changes in nursing regulation and the authority of the code

While the first nursing codes of ethics, both nationally and internationally, were grounded in human rights, professional organizations grappled with nursing’s mandate and role, and unions and regulatory bodies began to influence the objectives of the code. ¹⁹ These changes had many impacts on the mandate of CNA that is outside the scope of this article, but one significant change is in the authority of the code of ethics and its place in nursing. Up until these provincial changes, CNA had mirrored the previous provincial model of being the national nursing voice for the profession and regulator.

These changes began in the early to mid-part of the 20th century when Canadian nursing organizations oversaw the interests of the profession (including regulation) and labour rights. In 1988, a global initiative, led by ICN/Florence Nightingale International Foundation (FNIF), advocated for nursing to adopt a regulatory framework that would oversee the professional standards and the scope of nursing practice in order to standardize and maintain control over its professional practice. ⁴⁴ After the launch of a massive campaign for nursing regulation and conducting global workshops gaining insights from 99 National Nursing Associations (NNAs), it became clear that nurses had a tremendous range in scope of practice, but were dominated by physician-led policy and vulnerable to political trends, and if nursing did not make a move to self-regulation, they would be at the mercy of those outside of the profession. ⁴⁴

Throughout the 2000s, provincial nursing organizations successfully advocated for the right to self-regulation except for the College of Nurses of Ontario (CNO) which had already claimed self-regulation since 1963. ⁴⁵ The provincial nursing associations adopted the responsibilities of the regulator while also maintaining their roots of advocacy for the profession and healthcare policy. As a result of the self-regulation movement, essential changes in healthcare legislation followed that affected the mandate of three provincial nursing organizations to date, British Columbia, Manitoba and Nova Scotia. In these provinces, nursing regulatory bodies could no longer hold a dual mandate of professional body and regulator and could only assert the role of regulator. The political climate suggests that this trend will continue, and from these changes, three distinctive nursing organizations have emerged provincially and nationally: associations acting on behalf of the profession, unions acting on behalf of the nursing labour force, and regulators acting on behalf of the public.

In 2011, a new national nursing was born: the Canadian Council of Registered Nurse Regulators (CCRNR). ⁴⁶ The tensions surrounding the role of the code in the context of regulation came to a head in the 2008 revision. The contention was in philosophical views between the provinces that had been impacted by government legislation that called for provincial regulatory codes and traditionalists who advocated for a national code that upheld aspirational ethics and a movement towards social justice. ¹⁹ Despite the turmoil surrounding the future of the code, it remains in the hands of Canada’s national nursing association.

Today, as a self-regulating profession with the mandate to protect the public, nursing is bound by a code of ethics, and the CNA code remains the aspirational, and now regulatory, guide to the ethical values and responsibilities of nurses. ⁴⁶ In an attempt to find common ground, CNA and CCRNR released a joint fact sheet describing a complementary relationship concerning the code of ethics and that both organizations would oversee:

The development and maintenance of a code of ethics for RNs. In this instance, CNA establishes and upholds a values base for the profession, which individual nurses and many regulatory organizations adopt for use (in whole or part) in meeting ethical standards. (p. 4) ⁴⁶

Human rights and Indigenous Peoples in Canada

In the 2017 CNA code, the description of human rights mirrors what is written in the 2008 code. ⁶ There are two changes to the most recent code in the context of human rights – both focus on the rights of Indigenous Peoples. ⁶ One is located under the heading of justice and implies that ‘Nurses respect the special history and interests of Indigenous Peoples as articulated in the Truth and Reconciliation Commission of Canada’s (TRC) Calls to Action (2012)’ (p. 15). ^6,49 There is certainly an imperative within the Canadian nursing context to ensure that the impact of historical and present-day anti-Indigenous racism and colonial legacie are present and named in policy. However, this language falls significantly short in the urgency needed to fully recognize the rights of Indigenous Peoples in Canada. For example, this statement chooses to articulate that nurses are merely responsible ‘respecting’ the ‘special history and interests of Indigenous Peoples’, rather than other verbs used throughout the document such as ‘intervene’ or ‘advocate’. ⁶ It is particularly important to remember that this code is not only purported to be regulatory (which we previously argue holds very little authority), but this document is intended to be aspirational. Thus, in recognizing that the code is supposed to be (partially) aspirational, the included statement falls gravely short of what Canadian nurses have the power to act on in combating anti-Indigenous racism and upholding Indigenous rights within the health system. Furthermore, by using the phrase ‘special history and interests’ instead of naming and acknowledging the pervasive historical and ongoing colonial systems and structures in Canada (and nursing), the very ‘Truth’ that the TRC is ‘calling to action’ is erased.

The second addition to the 2017 code in the context of human rights focusing on Indigenous Peoples states that nurses are ‘Calling on all levels of government to acknowledge the current state of Indigenous health in Canada and to implement healthcare rights and take actions with Indigenous people to improve their health services (TRC, 2015)’ (p. 19). ⁶ Again, while this is integral, the very nature of a code itself is about ethical action and imperatives that nurses need to practice within. By outlining in this statement that the action needed to improve Indigenous health in Canada lies with the government, nurses’ ethical responsibility in Indigenous rights is abdicated. Similar to Kikuchi’s ³⁹ critique of the 2002 code where they cite the poor definition of ‘human rights’, the 2017 code lacks clarity in terms of what is meant by ‘respect for the special history of Indigenous peoples’ and calling on ‘government’ versus nurses to ‘acknowledge’ Indigenous health rights. Finally, what ‘Indigenous healthcare rights’ refers to is not clearly defined, nor is the intended sentiment.

In both the statements added on Indigenous rights, the Truth and Reconciliation Commission’s Calls to Action are cited as the primary reference for the inclusion of Indigenous healthcare rights. ⁴⁹ Yet, given previous trends for the codes to reference primary sources of human rights policy such as the Canadian Charter of Rights and Freedoms (CCRF) and the UDHR, the 2017 code does not reference the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), adopted by Canada in 2010 (only after significant political pressure due to being one of the four countries to oppose the declaration), ⁵⁰ nor does it cite the Royal Commission on Aboriginal Peoples or the CCRF as guiding policies or frameworks for Indigenous rights. ^51,52 While this is perhaps a first attempt to acknowledge the sovereignty and rights of Indigenous Peoples in Canada, it requires further guidance, detail and adoption of the frameworks that do exist. This could include UNDRIP and more radical rights-based statements to guide nurses in their ethical practice to best support the rights of Indigenous Peoples in Canada. Finally, even if a robust and strong statement on the rights of Indigenous Peoples in Canada is present in the next iteration, the difficulty in ascertaining the authority of the code remains.

In the coming decade, nursing must consider our legacy regarding human rights within the code, but perhaps more importantly, the role of the code within nursing. For 60 years, the code has been the moral compass for our profession, guiding not only our practice but also our collective ethical obligations to the people we can for and to one another. Arguably, human rights have always been at the core of our work, whether it was stated explicitly or not, and it is incumbent upon future nursing generations to establish clarity and uphold the integrity of a code that has been a beacon in being a highly trusted profession.

Conclusion

The historical examination and evaluation of human rights in nursing policy allows us to consider its current relevance and how it is or is not prioritized in nursing’s professional responsibilities today. Political influences, philosophical trends and the conceptualization of human rights have shifted how human rights are taken up within Canada’s nursing code of ethics. As the only official nursing policy on human rights with any authority, it is imperative that nursing’s code of ethics articulate human rights in a way that upholds the integrity of the very foundation of human dignity, value and worth – all of which are at the core of nursing care. The nursing profession must consider the implications and impact of the evolution of the code of ethics on present-day human rights and nursing’s mandate to protect the public. It is critical that the nursing profession has a clear and robust mandate for the ethical responsibility of nurses to protect the human rights of people living in Canada and around the world.