Keynote #3: Nursing Ethics: Archeology and Exegesis – Marsha Fowler, PhD, RN, FAAN

INANE Conference: Wednesday AM 8/6/25

Speaker: Marsha Fowler, PhD, Mdiv, MS RN, FAAN, FRSA (London), Professor of Ethics Emerita

Abstract: Marsha Fowler is the author of Nursing Ethics, 1880s to the Present; An Archaeology of Lost Wisdom and Identity, published by Routledge in 2024. In this book, Dr. Fowler interweaves real-life stories of the people who shaped the foundation of the discipline with her sharp-witted analysis of how their wisdom can inform today’s nursing practice. This work represents the culmination of years of research, examining original writings of nurse leaders in books and journal articles over more than a century. Her extensive research documents a unique nursing ethics focused on relationships. Dr. Fowler also brings her unparalleled wisdom and wit to the Nursology.net blog. In this presentation, she will focus on the critical role of nursing editors and publishers who have produced the evidence that makes her work possible.

Summary:

Chapter 1: Archeology of Nursing Ethics

• Dissertation: Ethics & Nursing, 1893-1984: The Ideal of Service, the Reality of History (University of Southern California) 
• She has spent 50 years identifying, scrounging, and gathering the nursing ethics literature that is being lost by the minute!
• The research is entirely dependent upon published, paper sources: nursing journals, textbooks, and miscellaneous speeches, lectures, and meeting minutes.
• In the process of this research, she has found 100 nursing textbooks and editions related to nursing ethics
  • Eg: Charlotte Aikens, 1st edition 1916 and 5th edition 1943
  • As many as 11 nursing ethics textbooks in any given year
• When nursing moved from the hospital SON to the university SON, the nursing libraries were not brought over. Nursing Ethics textbooks were then taken from nurses and handed over to philosophers and theologians, who were very out of touch with nursing and didn’t want them. So they disregarded them!
• The “First Chapters” on nursing ethics ~ were in med-surg textbooks from the late 1800s, into the early 1900s
  • Med-surg textbooks have their first chapters on ethics, usually on moral character (virtue ethics), or moral relationships
  • “Things moved from ethics to enemas in these books.” ~Dr. Fowler
• There were also journals, and Dr. Fowler did a page-by-page review of these resources

• Unfortunately, these old journals are literally falling apart
• These journals were sent to a “bindery”, which hatched out all the classified ads, advertisements, covers (with Vol & number), indices, and more! This is important because these ads gave you an idea of when certain specialties or trends of nursing started (like when nurses started riding bicycles to deliver home care!)

• When she reads this literature, she experiences a range of emotions, especially sadness for what has been lost. 
• More sources she has obtained and read through:
  • NLNE minutes, 
  • ICN speeches, meetings, minutes
  • ANA meeting/minutes
  • ICN & national ethics committees minutes
  • Commencement addresses
  • Organizational documents (codes, policies)
  • Weird and wonderful ephemera
• As you know, acid paper, onion skin paper, carbon copies, and the “poe’s”– fourth carbon copy keystroke made counter holes
• She has accumulated all of these for her own library (including every ethics textbook that has been published from 1900-1965 in the US, Canada, & UK)
• And then one fateful day, on January 8th, 2025, her home was consumed by a wildfire. This was a loss to our entire profession because she had artifacts that no one else had

“This represents the loss of nursing’s non-scientific literature to disregard, neglect, disintegration, discard, and “misfortune and calamity.” ~Dr. Marsha Fowler

• The humanities are essential—ESSENTIAL, because they embed the meaning and value structures of society and nursing. These structures challenge the power structures. The humanities see into the motivations, aims, and social consequences of the sciences.

Chapter 2: The Development of Nursing Ethics

• She is talking about “nursing ethics” BEFORE the existence of bioethics

• From the earliest days of nursing, there has been a collection of “moral relationships” of nursing, which are a structure for nursing ethics.

“Of society and by character, nursing ethics begins as a social ethics.” ~Dr. Marsha Fowler

• Nursing ethics from the start was SOCIALLY ORIENTED and POLITICALLY ENGAGED.
• We wanted an educated and scientific profession that was not that of a maid.
• Early nurses were in the homes and neighborhoods and observed, first hand, the social determinants of health, and WERE ENGAGED in dealing with them. 
• The five relationship structure means that nursing ethics is NOT solely patient-oriented and inherently encompasses every facet of health, including PROFESSIONAL, POLITICAL, ECONOMIC, SOCIAL, CULTURAL, RELIGIOUS, ENVIRONMENTAL, NATIONAL, GLOBAL, PREVENTATIVE, and INTERVENTIONAL.
• Nurses were encouraged to visit other countries and see how nurses practiced abroad, and articles were then published in journals about these experiences.

• Medical ethics focuses mostly on cost and access to care, not social determinants of health
• The new Nursing Code of Ethics was published in 2025.

“The Nursing Code of Ethics has been intrinsically, fundamentally, resolutely, intractably, willfully, definitely, and proudly DEI since 1873. If we betray this, we betray our social covenant that we are the most trusted profession, and we can’t give that up!” ~Dr. Marsha Fowler

• #1 The loss of nursing documents is a HUGE problem. It is imperative that nursing preserve its non-scientific journals, documents, and books that embed the humanities, values, virtues, obligations, and moral relationships for the sake of :
• #2 Nursing ethics as Social Ethics. As nursing transitioned into universities, it lost its social justice edge, its emphasis on ethics and moral formation, and its attention to nursing identity ~ partly because it lost its ethical literature and its knowledge or nursing ethics. Many philosophers and theologians dismiss nursing ethics as ethics. They never were interested in nurse-to-patient relationships or nursing altogether.
  • Dr. Fowler believes that every journal should have a 
• #3 Nursing as resolutely DEI
  • Dr. Fowler showed us the “banned words” list. The words circled in yellow are in the ANA code of ethics, and the words in brown were in the code in some form. 
  • Nursing values are NOT included in the banned word list! Does that mean nursing is not speaking up? Does that mean nursing is conflict-averse? Does it mean nursing is being ignored and dismissed? Does it mean nursing is not valued until you need a nurse? 
  • Where are the nursing terms and values?? Somewhere, “we screwed up” because our voice was not loud enough to get those words on that list. 
  • The lesson here is that we must try harder to use ALL the banned words on the list. We need to get nursing’s ethical commitments added TO the banned list! 

• Final Advice to Nursing Editors from Dr. Fowler:
  • Work to find and preserve nursing’s historic non-scientific literature
  • Work to reclaim nursing’s commitment to social ethics by making space for nonscientific research articles in the journals and special issues.
  • Don’t fiddle while Rome burns. Rome is burning, and we need our voice to be LOUDER THAN EVER! And we need NOT be conflict-avoidant. And we need to know nursing has VERY LITTLE TO LOSE by fighting back. There is power in numbers. We must raise our voices and say, “This is not right.”

QUESTION & ANSWER:

• Q1: What are your recommendations for nurse leaders/ethics on how to get the new ANA code of ethics out to ALL nurses?
  • Answer: We have tried for many years. It should be introduced to students in their nursing education, but it usually gets assigned as a freshman year reading, and it should be leveled across the curriculum, not just as a one-time assignment. The difference between now and when we moved into universities, ethics was viewed as INTRINSIC to nursing then. Early in modern nursing, ethics received HALF the curriculum time, as much as med-surg content! Ethics was to be included in EVERY single course in our history. Ethics was seen as “baked into the cake of nursing. Ethics now is seen as the frosting.” The other problem is that we don’t have faculty to teach ethics in nursing, because they tend to be already bogged down with different classes and not being an expert in ethics. We have to address this educational deficit. We also have to reclaim our commitment ot social ethics, it is who we are! We can’t just talk about patient care without policy! We have to work at several levels to bring in the code and teach ethics. In 1985, the committee attempted to include bioethics into the code of nursing ethics, but they couldn’t fit it in because it didn’t fit! 

• Q2: I was moved by the pictures of your home burning down. My question is, when we come across these artifacts, what do we do to preserve them? What ideas do you have? 
  • Answer: For me, it’s been a hard slog. I have offered my collection to multiple libraries, and one library was headed by a guy who didn’t think it was of “sufficient substance to include” and didn’t think it was important. It is a problem. We need to have the nursing editors press libraries willing to create a nursing textbook collection with our nursing textbooks. Another issue is that our “citations’ need to be digital and “within the past 5-10 years.” I need the editors to find a place that will take on this mission! England is very interested, and luckily, before my house burned down, I had moved some textbooks there. But I want you to be able to do this research within the U.S. We have to find funding.

 

• Q3: I am chair of the bioethics committee in my hospital, and the bioethical lens is the structure and format by which we evaluate ethical dilemmas. I advocate for the nurse’s voice to be heard. But I could do more. We have a resident ethicst trained at Columbia but we need more nursing ethics representation.
  • Answer: Most ethics programs offered to nurses to get a degree in ethics are BIOethics, which is the equivalent of a DNP to PhD. The bioethics degrees are basically rooted in the bioethics literature and don’t go outside it. Many bioethicists have never read actual philosophers’ primary works. Bioethics is a multidisciplinary applied field that doesn’t usually include nurses, except for tokenism. Part of the problem is that we are asking nursing to reclaim nursing ethics, but not teaching them about nursing ethics, so they can’t really articulate the nurse’s ethical position because they don’t know. I saw a TV program called “My Year at Oxford.” But the story’s substance is that a woman goes to Oxford to spend a year studying Victorian poetry, she meets a jerk, whose father is very wealthy, and she falls in love with him. She discovers by accident that he has a genetic cancer. His older brother had the same genetic cancer. And the brother died a miserable death fighting with every single treatment available, etc, and ultimately died. Now the other son, with whom she’s in love, is symptomatic. He had seen his brother die, and so didn’t want treatment. This caused a rupture in the relationship with his father, who was distraught by this. Yet the son continues to refuse treatment. Now, if you take this to a bioethics committee, you get “respect for autonomy, he can refuse treatment.” But what would a nurse say? She would look at RELATIONSHIPS, it would be not only to respect patient autonomy but also to HEAL the relationship between the father and the son. But we don’t teach nurses to say “get off this autonomy stuff, look at what’s actually going on!” Nursing ethics comes out best when a CHAPLIN is the head of the committee. However, we are not teaching nurses to tease out the NURSING ethical perspective on this issue. We’re only teaching them about autonomy, justice, nonmaleficence, etc.

 

• Q4: One way to find old texts is on eBay! But my question is: I am a PhD student. I don’t work in academia. I have always been a bedside/practicing nurse. I don’t think anyone here will disagree with what I hear in this conversation about nursing ethics. However, how do we convince the majority of nurses? If you are going to talk to bedside nurses, we can’t just be educating them when they are students. I have been questioning this important issue: how do we get non-academic nurses to understand the importance of NURSING ethics
  • Answer: Part of the answer is journal articles. 

 

• Comment: We are so limited in our thinking about bioethics because we do not think of system lenses. Even when we have the code of ethics, it’s also very difficult to understand it. I truly believe that, as an editor, I am going back to those five relational elements that will allow us to drive social change.
  • Answer: I think bioethics lacks a relationship structure and doesn’t think outside of the hospital walls. 

 

• Q5: I have one of those old “skinny green books” I rescued from a library throw away pile. I read it, and there was great focus on dress and comportment. How is this really about ethics?
  • Answer: Ethics used to be taught in a first-patient narrative in these old textbooks. You need to look underneath for the value in these narrative statements. When these textbooks talk about things like “make sure the patient’s food is a good temperature,” that is really about COMFORT. Comfort is the value. Another lost thing was that all of those early textbooks had one or two textbooks on “nurses’ care of self.” There is nothing in bioethics about the care of the self! It’s partly a reflection of women’s literature and the failure of men to read this literature as it should be read, as the “living out” of one’s ethics. 
• Comment: This reminds me of my own dissertation, where I deconstructed hysteria, and the take-home message is when women take care of women, there is no hysteria. When men take care of women, hysteria is rampant. We have to deconstruct this! I have found that literature about ancient women healers, witches, midwives, etc,  is lost/ignored. The other comment is as a psych nurse, I will say in psych we do this, this is very much a part of how we talk to patients, we look outside of the box, and that type of thinking is discredited by medicine. The other disturbing thing is that students are not exposed to nursing theory. But that’s where I learned about nursing ethics early on! Can we pull nursing ethics into our theory courses? My students didn’t even know who Barbara Carper was! We have to remember our roots.
  • Answer: I agree. Thank you. One of the things we have lost in nursing is the “identity of the nurse.” To be a nurse is to BE a nurse, not to DO nursing tasks. We need to internalize the values of the profession. I am never not a nurse, and that is what it means to be a nurse. We need to bring in the notion of the identiy of the nurse when we mentor nurses because that is the core of ethics. 

 

• Comment: In April, I wrote an editorial about self-care in nursing, and nurses wrote back, saying, “The organization I work for prevents me from doing this.” Every editor needs to write about the Code of Ethics, buy the code, and give it away to everyone they work with (not just nurses). When we all wrote about predatory journals in 2014, that was effective!

Your INANE 2025 reporter is Melissa Anne DuBois, BSN, RNC-OB, PhD Student.

Content for this post was obtained from the INANE 2025 website, the conference guidebook, internet searches, speaker submitted bios, and live reporting from each session. Any errors in content are purely accidental and not intended to offend. If you notice an error you would like corrected, please contact Melissa Anne at melissadubois2 at gmail dot com and she will be happy to make corrections.