Ethics in Nursing and Health Care Reform: Back to the Future?

Abstract

Reflection on the relationship of ethics in the nursing profession and current efforts to reform health care is a kaleidoscope of varied pieces and patterns. Current reform efforts at the federal and state levels point to nursing's social mandate--to help serve society's interests in the areas of health and sickness care. Because ethics in nursing has historically contained themes of reformation of institutional and professional values, responsibilities, relationships, and power with a goal of assuring patient welfare, the nursing profession can look to its past for the ethical resources it will require as it participates in the present moment of health care reform. Two major themes of nursing obligation return to the work of Florence Nightingale, administrator, statistician, and the founder of modern nursing. Nightingale's foundational views of nursing included the development of healing environments as a nursing responsibility and nurses' obligations to protect patient confidentiality. Both themes point to an ethics of institutional and social obligations as well as obligations to individual patients. These themes are juxtaposed in current discussions of ethics in nursing and in today's debates about the value foundations of reforming the delivery of health care. Tensions in nursing among loyalty to patients, to physicians, to self, and to employing agencies provide a context for the development of ethics in nursing over the past century and nursing's participation in health care reform today. Early twentieth century nursing ethics texts contain a potpourri of topics under the rubric of ethics. Nursing virtues of loyalty and obedience, heavily influenced by religious and military traditions, were foundational to the development of nursing obligations. An uneasy tension was already evident in these early discussions of ethics in nursing between promoting patient welfare as a primary emphasis and promoting the welfare of nurses through adequate reimbursement, suggesting that the welfare of nurses and patients is interrelated. Ethics in practice focused primarily on loyalty to physicians and to employing institutions. Nursing was largely dependent in reality on the prevailing ethics and values of medicine and bureaucratic institutions such as hospitals, where most nurses' training took place. A separate ethics for the nursing profession was discouraged by influential physicians even as nursing leaders struggled to professionalize nursing. In the 1930s and 1940s broader humanistic themes emerged that pointed to nurses' obligations as citizens of the community and the world. Nursing leaders encouraged nurses to participate in politics in order to facilitate the achievement of nursing and health care goals. The theme of citizenship was explicit even in the first efforts by the American Nurses Association (ANA) to develop a nursing code of ethics in the late 1920s, although the first ethics code for nurses was not officially approved by the ANA until 1950. …