A solitary dialysis machine in Seattle in 1962, with too many patients needing it, did not create bioethics. Neither did it give rise to nursing ethics. The proof rests in modern nursing ethics’ ~170 year lineage.
Because of that lineage, I am now flunking retirement. I have been captivated and gripped by nursing ethics, its scope and depth, its sagacity and genius, its perspicacity and capaciousness. This has led me to begin a search, back into nursing ethics, and further back, and even further back, to trace the origins of the fundamental concepts of nursing ethics today. These include the relational structure of our ethics, the primacy of the patient, the fusion of nursing experience with ethics, and more. I am seeking the provenance, literary chain of custody, authenticity and more for all these foundational concepts.
The lineage of the relational structure of nursing ethics is startling. Nursing ethics currently identifies a structure of six relationships, nurse to patient/family, nurse to other health professionals, nurse to self, nurse to profession, nurse to society, nurse to the integral world (human and natural environments). Over almost 170 years these relationships have been configured and recombined, in accord with changes in the profession, or specific to a particular author’s audience. Each one of these relationships gives rise to specific normative obligations and values of nurses and nursing, inherent to that relationship. The early authors identified the duties, virtues, and values for each relationship that became the deontic[2] and aretaic[3] norms and normative teloi[4] of the profession.
Though the number of structural relationships have been differently configured, combined, and identified over time, they have remarkable stability in content. Various authors chose to explicate only one or two relationships, without specifying others, and some explored an expanded list depending on their audience. As I look back in the literature I seek a relational structure that is specifically infused with moral norms, not simply relationships that detail clinical responsibilities. I have excluded those works that only address relationships in clinical practice that are customarily focused on medically-delegated duties, found in books often jointly written with or edited by a physician.
The oldest material I’ve found thus far is Florence Sarah Lees’ Handbook for Hospital Sisters (1874).[5] Within the nurse-to-patient relationship, Lees identifies morally structured duties, while also addressing the relationship of the nurse to other nurses. It is significant that her work provides evidence that the nurse-to-patient relationship was already morally constituted by 1874, eleven years prior to Sarah Weeks’ three-fold specification of ethical relationships in 1885.
Sarah Weeks (later Weeks-Shaw) is the earliest source I found that explicitly classifies nursing duties relationally, in three (four?) ethical relationships — nurse to self, to physician, and to patient, with an additional obligation to one’s nursing school that she does not specifically count as a relationship. Weeks specifies ethical content[6] for each relationship and the ethical content is inseparably joined to skilled nursing. However, Weeks’s structure is not merely relational; it contains a priority ordering within the relational structure. The existence of duties to physician, self, patient, and school does not mean that all relational claims have equal standing. Her declaration that the patient’s welfare is the “first consideration” suggests that the nurse–patient relationship has a distinctive priority when the moral claims of the several relationships might compete with one another.[7] I believe this declaration, and findings elsewhere support it, is what we today specify as the primacy of the patient, but that is a topic for another day.
Shortly after Weeks we find Harriet Camp (later Camp Lounsbury) who describes an ethical structure with seven relationships in her 1889 journal article series,[8] as well as in her book.[9] Camp writes that “for convenience sake” she will divide the duties of a nurse into seven classes. She establishes the seven as duties and to whom they are owed: the patient, the doctor; the patient’s family, friends, and servants; herself, her own friends, her hospital or school, and other nurses. Camp’s configuration reflects what was then the role of the nurse (care took place in the home), and the structure of nursing school-based “registries” that assigned cases/employment. These nurses were the audience for her speeches. A crucial point is that these are relational classes of ethical duty.
Camp is organizing nursing’s ethical content according to whom the nurse owes something. What makes this schema distinctive is that “ethical conflicts,” where they might exist, are not a matter of conflicts of principles, or conflicts of values, rather they are conflicts of relationships: for example, a conflict between the nurse’s duty to the patient versus duty to the physician. In this period, this specific conflict becomes the ground for the moral norm of the patient as the first object of obligation.
The relational structure of nursing ethics is but a small foretaste of the rich provenance of nursing ethics. Fully tracing the relational structure requires a continued examination through the remaining nursing ethical literature from 1900 to the present, a task well beyond the scope of a blog. There is more work to be done! This is but an invitation to join us in the pool of nursing ethics; the water is warm and inviting – wade on in!
[2] From the Greek root deon, meaning “that which is obligatory”; referring to what we are to do, right or wrong.
[3] From the Greek word aretē, which means excellence or virtue; generally referring to what we are to be in a moral sense, good or evil.
[4] From the Greek, teloi, the plural form of the word telos, meaning ends, which refers to ultimate purposes or goals, that are sought.
[5] Florence Lees. Handbook for Hospital Sisters. Henry W. Acland, ed. London : W. Isbister, 1874.
[6] By ethical content I mean content that is either aretaic or deontic or both
[7] Weeks, Clara S. A Text-Book of Nursing: For the Use of Training Schools, Families, and Private Students. New York: D. Appleton and Company, 1885.
[8] H.C.C. [Harriet C. Camp]. “The Ethics of Nursing: Talks of a Superintendent with Her Graduating Class.” The Trained Nurse 2, no. 5 (May 1889): 179–183.
[9] Camp, Harriet C. [later Harriet Camp Lounsbery]. Making Good on Private Duty: Practical Hints to Graduate Nurses. Philadelphia: JB Lippincott 1912. (Camp, 1889; Camp-Lounsbury,1912)