The field and practice of nursing ethics has developed enormously in modern times. Nevertheless, it is evident that the ethical challenges ahead are as great as they have ever been and that there is no room for complacency. Ironically, one of the biggest challenges facing the nursing profession at this time is not how best to deal with the complex ethical issues facing nurses, but how to get nurses involved at all and to take the action necessary to improve the moral status quo. In this chapter, attention is given to two key issues: nursing ethics futures, and the need for nurses to engage in moral activism in order to challenge and change the moral status quo — particularly in regard to promoting and protecting the public’s health.

As I have discussed at length elsewhere (Johnstone 2002b), contemporary health care ethics/bioethics has become preoccupied with the issue of people’s rights to and in health care (e.g. the rights to informed consent, confidentiality, quality of life, death with dignity, and so forth). There is no question (as the preceding chapters in this book have amply demonstrated) that this preoccupation has achieved some morally significant and beneficial outcomes in health care domains. Nevertheless, it is equally evident that health care ethics has not achieved its most basic task, namely, to promote and protect the genuine wellbeing and welfare interests of those who are among the most vulnerable people in society and whose health is at risk.

It has long been recognised that although access to health care is an important determinant in ensuring the health of people, it is not the only or even the most important determinant (Daniels 2006; McMurray 2007; Wilkinson & Marmot 2003). The health of people rests on a much more complex array of conditions and processes. For instance, it is known that the public’s health is deeply rooted in social, cultural, economic and political circumstances and that if the health of people is to be achieved, these conditions need to be understood and considered (Anand et al 2004; Daniels 2006; McMurray 2007; Mann et al 1999; Wilkinson & Marmot 2003). It is also known that, to achieve the goal of health, people need to be situated in a ‘strong, mutually supportive and non-exploitative community’ (World Health Organization [WHO] 1995: 4). Over the past four decades this knowledge has seen cycles of public attention given to such things as poverty, unemployment, poor housing, racial discrimination, homophobia, cultural dispossession, social isolation, and the impact these conditions have had on the health of people. But, as commentators observed as early as 1975, ‘this attention and interest rapidly wane when it becomes clear that solving these problems requires painful costs that the dominant interests in society are unwilling to pay. Our public ethics do not seem to fit our public problems’ (Beauchamp 1975: 20).

In several respects the emergence of the bioethics movement in the early 1970s was an attempt to challenge and change the status quo and to redress the lack of ‘fit’ between ‘public ethics’ and ‘public problems’. The development of the contemporary health care ethics movement (a correlative of bioethics and often treated as being synonymous with bioethics) sought similarly to challenge and change the status quo. Today, however, it is evident that neither the bioethics movement nor the health care ethics movement has succeeded at their most basic task, namely, to promote and protect the public’s moral interest in health (Daniels 2006). It is also evident that if health care ethics is to ‘fit’ the world’s health problems — and if it is to succeed in promoting the moral interests that are inherent in a positive health status — then a shift in its focus is required.

Members of the nursing profession are in a good position to challenge and champion a change in direction in health care ethics. This, however, would fundamentally require the nursing profession to take responsibility for the future by developing an ‘ethics of the future’; that is, an ethics that focuses on anticipating and preventing the mistakes that will become future problems (Mayor & Binde 2001). Leading and operationalising a strategic program of nursing ethics future, in turn, would also require nurses to become involved, in a genuine individual participatory sense, to challenge and change the moral status quo in the domain of health promotion and health care.