1. Fowler, Marsha D.

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For many years I had privileged access to the emerging field of bioethics (before most of nursing became aware of the new field). There was a small coterie of us, in the 1970s and early 1980s, who received a Kennedy Fellowship in Medical Ethics. Eventually, with the publication of Beauchamp and Childress's book, The Principles of Biomedical Ethics (1978), the term shifted from medical ethics to biomedical ethics, and eventually to bioethics. We Fellows were educated in Utilitarianism and Kantianism and solidly versed in ethical principalism from the book and the Belmont Report (Health & Human Services, 1979). After this intensive medical ethics fellowship, we were to take medical ethics into our nursing curriculum.

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With years of immersion in bioethics, I never felt that it fit nursing. It seemed an attempt to shoehorn nursing into a shoe that did not fit. Bioethics mostly dealt with issues that were not nursing issues (nurses do not order a ventilator or treatment cessation). Moreover, bioethics had no interest in the issues that arose in day-to-day nursing care or in the social issues that commanded nursing's attention. However, I (wrongly) continued to promulgate what I had been taught, until...


...until I discovered that nursing had an enormous, dedicated, body of nursing ethics literature, by nurses for nurses, that began in the later 1800s and continued unabated until nursing moved into colleges and universities. Isabel Robb wrote the textbook, Nursing Ethics, published in 1900. Many other nursing ethics textbooks would follow, with hundreds of journal articles in the American Journal of Nursing. Reading these books and articles is like going home, only to find it is a finely built palace, not a rustic log cabin that you remembered. Let me introduce you to Charlotte Aikens' book, Studies in Ethics for Nurses, published in 1916. Her textbook went on to five editions, the last published in 1943.


In this period, nursing takes place largely in three venues: in patient homes (the majority), in hospitals (under 20%), and in visiting and public health nursing. Consequently, many of the examples that Aikens presents are those that occur in homes. Cases in hospitals will mostly represent nursing instructor or student concerns as the students staffed the hospitals. Aikens offers first-person narratives that reflect both nursing experience and warmth. They are, however, informed by the fields of ethics, politics, social justice, and feminism, and are nursing focused. They reflect multiple core commitments-to the patient, to the nursing student or nurse, to society, and to humanity. And they are intimately nursing.


Aikens' 1916 textbook systematically covers the nurse herself (her in this period), personality, conduct, duty, virtues, nursing values in practice: accidents, mistakes, and errors; tact and imagination, the tone [moral environment] of a school, developing a balanced life; health, recreation, and friendship; the wide nursing world after graduation, cooperation for social and international purposes, and much more. There is a chapter on each of these, illustrated with examples. Consider these examples (direct quotes) that Aikens gives, but look beyond the dated specifics to contemporary practice:


Think about COVID...


A doctor asks a nurse who has just returned from a case of scarlet fever to assist him at an operation the following morning. He insists that there is no danger. The nurse fears that she might carry infection. What should she do when the doctor says he will assume all responsibility? (p. 295)


Think about the double-bind, truth-telling, and paternalism/gender...


A nurse is called to an obstetrical patient on the second day after the birth of the child. The baby's eyes are infected. The patient, privately to the nurse, blames the doctor...The doctor privately tells the nurse that the husband is to blame, and that he had previously had gonorrhea and thought himself cured. What should the nurse do when questioned by the patient as to how the infection occurred...? (pp. 300-301)


Think about patient cultural practices...


A nurse is called to nurse a child critically ill with pneumonia. The family wish her to apply onion poultices to the feet and to rub a certain ointment on the chest. The treatments will probably not do any harm. What should the nurse do about it? (p. 282)


Think about a nurse-educator's responsibilities...


A [student] nurse who has an unusual memory is able to pass written examinations taking a full 100% in many, and a high grade in all. Her practical work is very inferior. She seems to lack judgment and tact and is not always truthful. What should the principal do in regard to this case? What point should be considered? (p. 288)


There are approximately 100 examples in Aikens' book, drawn from day-to-day nursing. It is a nursing-specific ethics that Aiken advances, yet contemporary bioethicists have dismissed these early writings as dated expectations of womanliness and as "not really ethics." And yet, the examples that Aikens gives are anything but that.


Every chapter is followed by short essay questions that are as relevant today as they were when Aikens (1916) crafted them. These are questions of nursing ethics, questions in which medically normative bioethics has little interest:


* How may a nurse help in securing or maintaining the right moral atmosphere in a hospital? (p. 28)


* What ethical principle does a nurse violate when she gives to others information which has come to her because of her work as a nurse? (p. 59)


* Should the accepting from patients of small favors or other gifts be permitted among nurses in a hospital? (p. 79)


* What course should a nurse pursue who discovers that she has given a wrong dose of a medicine to a patient? (p. 161)


* What do you understand by the term "professional relations" [boundaries]? (p. 130)


* Are we ever placed in situations where it is impossible to do right, if we honestly want to do right? Give illustrations to prove that this is or is not so. (p. 142)


* Show how the quality of imagination in the nurse may affect the comfort of her patients. (p. 108)


* How may poise of soul be cultivated? (p. 42)



Aikens is concerned about the ethics of patient care, but also about the ethics of the nurse's care of self. She writes that nurses must develop a symmetrical life, that "every nurse has a fourfold nature to be cultivated and developed. She has a physical, mental, spiritual, and social side to her makeup, all needing care and cultivation" (p. 163). Only by developing a symmetrical life will the nurse "remember that we are dealing with afflicted souls, hungry souls, as well as afflicted bodies" (p. 103). Quoting physician Richard Cabot, Aikens relays (p. 138),


Our profession, the profession to which you as nurses and we as physicians contribute what we can, brings us constantly into the closest contact with human souls. We are with our fellow creatures in their hours of storm and stress when what is deepest and truest in them comes to light. Such contact is sure to affect us in one of two ways: it can enable us, or it can make us callous. There is no other alternative. Familiarity with the great spiritual experiences that attend birth, death, and bereavement, with the awful perplexity of choosing between one life and another, and the awful desolation of the sufferer who learns for the first time his malady is incurable, drives us all either to shut our ears to the poignant message of our work, hopeless of understanding its meaning, or else opens every sentence and every faculty to meet the world's revelations, with the faith that is the essence of religion.


This body of nursing ethics literature, that sees ethics and practice as inseparable, is the proper and welcoming ethics home for nurses, where nurses can be nurses, immersed in the values, virtues, ideals, and aspirations of nursing. It is also a literature where the nurse is a person whose faith informs and moves the nurse in skilled, wise, and compassionate nursing care.




* Take a moment to read some of Aikens' book (see url in references).


* What appeals to you the most about nursing ethics?



Aikens C. A. (1916). Studies in ethics for nurses. WB Saunders.[Context Link]


Beauchamp T., Childress J. (1978). Principles of biomedical ethics. Oxford University Press.


Health & Human Services. (1979). The Belmont Report: Ethical principles and guidelines for the protection of human subjects of research.[Context Link]