Nursing ethics as a distinct entity within bioethics: Implications for clinical ethics practice

Introduction

Whether or not nursing ethics is a distinct entity within the broader practice of bioethics is an important topic to address both because of its potential impacts on clinical ethics practices by nurses and also its implications for patient-centered care. Though fundamental bioethical principles are appreciated and applied within the education and practice of nursing ethics, ¹ we argue that there exist distinct considerations which make nursing ethics a unique subfield of bioethics. One might point to discrepancies in principles to be focused on as the root of difference; for example, Fahrenwald et al. center on five core values, including “human dignity, integrity, autonomy, altruism, and social justice” and not on the four principles of bioethics, ² while Raatikainen focuses on freedom, brotherhood, and equality. ³ The potential difference we note in this paper between nursing ethics and bioethics as they impact clinical ethics practice is not based on principle or value comparison, but rather on the deeply-imbued relational emphasis that is the ethos of nursing practice and how this need not be the case for clinical ethics practice that is informed solely by bioethics, at least by a bioethics rooted in the principlism made famous by the work of Beauchamp and Childress. ⁴

That is, in this article, we focus on the importance of relationships as a defining and framing feature of the foundation of nursing ethics. After highlighting the emphasis on relationships in nursing education, practice and, overall, in nursing science, we argue that this relationship focus distinguishes nursing ethics from other bioethical subfields. Next, we consider two objections to our claim of distinctiveness. First, we consider whether nursing ethics is not a distinct subfield of bioethics but rather that it is merely a particular application of bioethical principles. Second, we consider the objection that though nursing ethics may appear to be distinct; it cannot be because the mark of distinction is a feature that many bioethical subfields emphasize, relationships. We respond by highlighting that throughout nursing education and generally in every career path that follows, creating and nurturing relationships is emphasized. Compassion and respect for the dignity of every patient is the framework upon which these relationships are built. Furthermore, core tenants of nursing practice involve the ability of nurses to establish enduring therapeutic relationships ⁵ with patients and their families. Much of the focus of nursing science rests on creating meaningful interpersonal experiences and human connection. In these ways, nursing ethics is the relationship ethic, and though other bioethical subfields—and bioethics as a whole—may take relationships seriously, the role that this concept plays within their ethics is neither as foundational nor as pervasive as it is in nursing.

After responding to each objection, we turn our attention to the implications of this claim of distinctiveness on clinical ethics practice, arguing that though there are both strengths and limitations to our account of nursing ethics as distinctive, the strengths outweigh the limitations. It is important to highlight that we recognize that the practices of clinical ethics are diverse and may be diversifying further. It is not our contention that all clinical ethics consultants approach their work solely being informed by principlism. First, consider the novel activities of Norwegian clinical ethics committees. ⁶ Second, consider the different models for clinical ethics consultation; for example, single consultants might not need a theory or practices to resolve disagreement in the same way as ethics committees would, just to suggest one obvious structural difference. For a helpful explanation of different models, both the aforementioned and others, as employed in Canada, see the work of Kaposy C et al. ⁷ However, we do take notice of the prominence of principlism, which is our reason for highlighting it. As noted in a recently published guide for healthcare ethics committees, which adopts a principlist framework, while mentioning others:

Autonomy is the ethical principle widely considered most central to health care decision making. Its prominence here and in other bioethics literature reflects the heightened emphasis typically accorded patient rights, self-governance, and individual choice. Autonomy includes determination of health care goals, power over what is done to one’s body, and control of personal information. Only when the individual cannot make decisions are others asked to choose. Autonomy gives priority to personal values and wishes, supporting choices that are informed and uncoerced, and confers the professional obligation to respect patient privacy and confidentiality…” ⁸

The deep emphasis, within nursing ethics, on creating meaningful interpersonal experiences and human connection supports a greater integration of relationships ⁹ and social contexts ¹⁰ into the evaluation of whether an action is ethically permissible, which is an important benefit in addressing the challenging human situations that patients face. Moreover, this perspective allows nurse ethicists to account for diverse and complex social structures and their influence in making ethical determinations. We close by arguing that these strengths outweigh the limitations of potential inconsistencies between nurse and non-nurse clinical ethicists on the same service, a result we attribute to nursing ethics—and, in turn, the practice of the nurse ethicist—being framed by relationships ¹¹ to a larger extent than other bioethical ¹² subfields.

A foundation in relationships: The education, practice, and science of nursing

The basis of nursing education depends on the ability to swiftly and successfully build meaningful relationships. Forming relationships, as in many academic environments, often begins with one’s peers. However, what allows for a particular distinction in nursing education is the expectation that all nursing students will quickly learn how to develop meaningful relationships with the patients and their caregivers. The framework for these formative relationships with their patients is one of trust. Often these bourgeoning relationships are established between a student with little clinical knowledge and patients experiencing fear, suffering, and isolation. This is a challenging but necessary mission. There is a growing body of evidence from studies conducted worldwide linking nursing education curriculum fostering growth of trustworthiness in students to building resilience that prepares them for academic success, self-care, and care of others. ¹³

Within nursing practice, ethical challenges abound that will test the trust and durability of relationships between the nurse and patient. Ulrich et al. state, “Nurses are working on the front lines of care every day and often under conditions of uncertainty, or conflict that test their knowledge, values, and actions.” ¹⁴ It is these dynamic and ongoing challenges that call for such a strong emphasis on the ability to forge relationships. Though the critical importance of the bond between nurses and their patients cannot be understated, so too is the essential nature of the relationship between nurses and their interprofessional peers. The ability to effectively and efficiently articulate their patient’s concerns, values, and preferences to other healthcare professionals is the crux of delivering patient- and caregiver- or family-centered care. Nurses are the “common thread,” often bridging the gap in knowledge or communication with multiple clinical teams and many concerned family members. This difficult role can only be actualized by a nurse with the ability to make meaningful connections swiftly, while establishing trust and practicing advocacy.

This is also the case for those nurses who occupy roles as nurse ethicists. Though nurse ethicists and the approaches they take to ethical issues may vary, and sometimes widely, especially across the globe, the ability to make meaningful connections is essential. This type of clinical ethics support (consultation) is commonplace in the United States, but may not be worldwide. There is no consensus regarding the consultant’s role globally, and there is variability in the role itself and purpose, based upon the country. ¹⁵ Clinical ethics support may come in various forms (aside from clinical ethics consultation) globally. For example, according to Rasoal et al. ¹⁵ other forms of clinical ethics support may include clinical ethics committees, moral case deliberation, and ethics rounds/ethics discussion groups/ethics reflection groups. We, therefore, feel the need to underscore that we are deliberately focusing on the role of the nurse ethicist functioning within the clinical ethics consultation approach, though we are mindful that other methods of providing ethics support do exist.

Since we are sharply focusing on the role of the nurse ethicist within clinical ethics consultations, we need to draw attention to the practical challenges associated with this method, and acknowledge that these may vary, depending on the location of clinical practice, globally. Khoo et al. ¹⁶ acknowledge that clinical ethics consultation service remains undeveloped in developing countries, creating inconsistencies in this approach from a global standpoint; they state, “Cultural barriers, limited resources, lack of awareness, differences in opinions, fear of litigation and destructive influence of social media are seen as threats to the introduction of clinical ethics consultation service.” ¹⁶

Nursing ethics as distinct

The education, practice, and science of nursing, as described in brief in the previous section, form the foundation of the distinctiveness of nursing ethical practice and inform our understanding of the implications for nurses practicing as clinical ethicists. Nursing ethics is a distinct subfield of bioethics and what distinguishes it from other subfields is its focus on relationships. This is not to say that relationships are not important in other clinical ethics subfields or not recognized as important in bioethics, as a whole; rather it is to claim that the pervasiveness and the priority of the nurse’s focus on relationships—imbued through a nurse’s training, practice, and scientific approach, are not seen in other subfields of bioethics.

Objections considered

Some may argue that nursing ethics is not distinct, suggesting that it is simply an application of bioethical principles, while others may argue that nursing ethics is not distinct, suggesting that another subfield is sufficiently relationship focused. We take up each objection in turn. First, one might think that nursing ethics is merely an application of bioethical principles; that is, nursing ethics, like a physician ethic, is simply the principles of bioethics applied to particular health professions. Though this suggestion is important to consider, it is wrongheaded. This is for at least two reasons. First, to think of nursing ethics as merely an application of bioethical principles misses out on the role of relationships within nursing education, practice, and, in fact, the whole of nursing science. The most prominent principles in bioethics—at least for those who subscribe to the most common approach, principlism, are autonomy, beneficence, non-maleficence, and justice. The nurse ethicist takes these principles seriously but takes them on board in light of a strong orientation toward attending to relationships. Nurse ethicists do not merely ensure that a patient’s preferences are respected, as an autonomous agent, but rather aim to uphold their preferences amid a myriad of complex social and cultural features built upon an understanding of the importance of relationships within human life.

Second, to make this claim is to ignore the history of the profession of nursing, the rise of bioethics, and their relationship. In work published during the period of overlap, and approximately two decades after the birth of bioethics, Fry describes potential differences between bioethics and nursing ethics as rooted in their distinct theoretical support structures, noting:

“The development of nursing ethics as a field of inquiry has largely paralleled developments within the field of biomedical ethics. However…[t]he value foundations of nursing ethics are derived from the nature of the nurse-patient relationship instead of from models of patient good, rights-based notions of autonomy, or the social contract of professional practice as articulated in prominent theories of medical ethics.” ¹⁷

More recent work, which helps to provide a critical, historically- and socially-informed perspective serves to buttress Fry’s contention, three decades later. Fowler argues that as nursing has (and continues to) embrace bioethics a tension arises. Bioethics “fails to incorporate the rich ethical heritage, history, and literature of nursing prior to the development of the field of bioethics.” ¹⁸ Change is to be accepted, but “change must be contiguous with the tradition in which it arises lest that change become radically disjunctive, doing violence to or altogether obviating the tradition itself.” ¹⁸ For Fowler, the failure of bioethics to take seriously the history and ethical heritage of the nursing profession, even as the nursing profession has adopted bioethics creates the radical disjunction in nursing’s ethics.

The strongest case to be made that nursing is not distinct is by comparison to a bioethics subfield that has, to a significant degree, taken seriously the importance of relationships: clinical ethics. Thus, one might argue that nursing ethics is not distinct from clinical ethics, as clinical ethics is also demarcated by a relationship focus. In response, we argue nursing ethics’ focus on relationships is not the same as clinical ethics’ emphasis on relationships, at least as far as clinical ethics relies on a bioethics rooted in the principlism of Beauchamp and Childress. Clinical ethics is described as encompassing “general issues of bioethics, including health care systems, provider payment systems, health equity and justice, death, and disability.” ¹⁹ It is true that many practicing clinical ethicists take seriously the importance of relationships, and the practices of clinical ethics (by many) are influenced by this approach. Consider, for example, the increase in conflict resolution skills, training sessions, and discussion in the literature as an approach to clinical ethics consultation. (For example, from 1975–1990 19 articles address clinical ethics and conflict resolution, but from 1991 to 2022 there are over 560 articles indexed in Pub Med). Coordination of care meetings as a result of an ethics consult call or sitting down with families to discuss care with a care team and a clinical ethics consultant are good examples of situations in which relationships are often attended to by clinical ethics professionals. However, even here, it is not necessary to prioritize relationships, only common, and training in clinical ethics is not steeped in relationships in the way and to the degree that nursing ethics is. It may be true that clinical ethics consultation does often prioritize relationships in its ethical outlook and approach. However, our point still holds, as it is not the only accepted ethical approach to clinical ethics consultation; it is not baked into the professional identity of what it is to be a clinical ethicist; those are the case in nursing.

Further responses: The positive case for a distinct subfield

In the preceding sections, we made the case for nursing ethics as a distinct subfield but did so primarily through contrast with other subfields and by highlighting how the importance of relationships differs between nursing ethics and other areas of bioethics. We now take up the role of relationships in nursing ethics more directly, as a foundation for its distinctiveness. In response to the claim that nursing ethics is simply an application of bioethical principles, we must illustrate the significance of, not only relationships, but of relationship-building in nursing, as a necessary requirement of the profession, and how this requirement impacts the practice of ethics among nurses and the entire interprofessional team. We must also examine what other features distinguishes nursing from other related healthcare fields, and how, if at all, that influences access to ethics guidance.

Implications

If we are correct that nursing ethics is a distinct subfield of bioethics, then it is important to clarify what the implications are of this distinctness; in particular, what are the limitations and strengths of this account for nurses, patients, and for clinical ethics practice. We noted above that our claims are not to illustrate a superiority of nursing ethics over other bioethical subfields, which remains true in our measuring of the limitations and strengths. Rather, we suggest some strengths of this model and raise some concerns.

The deep emphasis on creating meaningful interpersonal experiences and human connection supports a greater integration of relationships and social contexts into the evaluation of whether an action is ethically permissible, which we see as an important benefit in addressing the challenging human situations that patients face. Patients are multi-faceted, intersectional, and, ultimately, complex beings who come to need care for different health concerns in light of a variety of human challenges, from diverse backgrounds, and operating within different distinct contexts. The relationship focus of nursing ethics and the nurse’s relationship-building expertise and professionally mandated expectation are epistemologically and practically well-suited for responding to patients in need of care. The nurse begins to understand and investigate the care needs of the patient, not through a chart, but through the building of relationships and, as articulated above, it is from this orientation that trust and, ultimately, successful care can be delivered. Moreover, this perspective allows nurse ethicists to account for diverse and complex social structures and their influence in making ethical determinations. Advocating for a patient, to take one example, involves recognizing and responding to health-impactful factors beyond direct healthcare, such as food or housing insecurities, internalized sexism or racism, or environmental discrimination. A relationship ethic is well-suited and a nurse ethicist well-situated to address a patient’s whole self and to care for a patient holistically.

There are also limitations in accepting our account of nursing ethics as a distinct subfield of bioethics. The greatest cost is the potential inconsistency between nurse ethicists and other clinical ethicists. That is, one might worry that if nursing ethics is understood to be distinct, this will lead to different kinds of clinical ethics services—those of nurse ethicists and those of non-nurse ethicists. This is not merely because one is a nurse and another is not, as there are physicians, social workers, and PhD bioethicists serving in these roles. Rather, the concern is that in affirming the distinctiveness of nursing ethics, a separate clinical ethic might be recognized and thus a lack of consistency in clinical ethics approaches and outcomes. If ethics is called for two consults on relevantly similar cases and two quite different assessments are offered, this—for some—would be problematic.

This is an important concern to consider, and we offer four responses to it. First, though not a powerful argument, it is already the case that there exists a diversity in clinical ethics practice. Consider the differences in hospitals or health systems (and even within them) which employ a single consultant model, as opposed to a team, or full ethics committee model. Further consider two clinical ethicists who might, even though both subscribe to a principlist approach, vary their weighting of the importance of principles—one prioritizing autonomy, another prioritizing beneficence. Second, it may be the case that though distinct, other clinical ethics approaches might in the future take more seriously the role of relationships in ethical practice and, thus, the distinctiveness of nursing clinical ethics would not appear so stark, in practice.

Third, giving nursing’s emphasis on relationship-building, including building relationships with colleagues, it stands to reason that other clinical ethicists might work well with nurse ethicists and so potential inconsistency in recommendations might be minimized.

Finally, and quite differently, it might be the case that differences exist and that is acceptable. Take, for example, the recent suggestion that clinical ethicists should support and even partake in disinformation or deception when patients or family members request care that is nonbeneficial or harmful. ²⁶ This approach may be available to some clinical ethicists, though not all, ²⁷ and it is surely not available to the nurse ethicist, considering the nursing emphasis on relationships and the importance of honest, trust-building communication. Though the nurse ethicist would offer a different recommendation than Meyers et al. this need not be viewed as a cost. Among the many goods of diversity is the opportunity for positive influence and for suggestive self-reflection in light of interaction with others. A nursing ethics approach, rooted in trust and relationships, might be a useful counterbalance to some concerning, even if nascently emerging, trends in clinical ethics.

We believe that the aforementioned strengths outweigh the limitations of potential inconsistencies between nurse and non-nurse clinical ethicists, even if those ethicists on the same service.

Conclusion

In this article, we have argued for the distinctiveness of nursing ethics as a unique subdiscipline of bioethics. We have highlighted that there exists disagreement, differences of opinion, and—in some instances, merely—different conceptualizations of the very broad cluster of questions, methodologies, and categories related to ethical reflection on health and healthcare. We have argued for the distinctness of nursing ethics as rooted within the practice of nursing and moored by nursing foundational emphasis on relationships. We have contrasted this approach (understood loosely) with other bioethical approaches, especially some versions of principlism-influenced clinical ethics. Our discussion is not exhaustive, and it is important to note that not all persons thinking about bioethical issues, practicing in clinical settings with titles that include “bioethics,” or attempting to enact policies under descriptions that include “bioethics” subscribe to the principlism of Beauchamp and Childress. We highlight that there exists a diversity of bioethical approaches; however, we also note the influence of this “four principles” approach, as well as the murky landscape of that cluster of academic and practical work interested in ethical considerations associated with health and healthcare. In sum, in our view, nursing ethics is not, on our account, just another application of bioethical principles. It is distinguished by its relationship focus. Though it is possible that recognizing this distinctiveness raises inconsistences in ethics recommendations, even for clinical ethics consultants on the same service, we have argued that the strengths outweigh the limitations. Nursing ethics is distinct and should be recognized as such.