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.

The need for nurses to take action to secure morally just outcomes in professional, social and political domains has perhaps never been greater on account of the complex array of social, cultural, economic and political processes (including the ‘assault on reason’³ and the ‘silencing of dissent’⁴ by governments) that are increasingly eroding the health and wellbeing of people around the world. Despite this need, and the mandate of the nursing profession to promote and protect health, moral activism by nurses seems conspicuously absent or, if it is present, remains largely invisible, prompting important questions concerning why this situation has occurred and what can be done about it.

As already stated in this book, the modern nursing profession worldwide has a rich and distinctive history of devising and upholding exemplary ethical standards of conduct and of taking action to address ethical issues arising in contexts relevant to the profession and practice of nursing. Furthermore, as the plethora of nursing literature dating back to Florence Nightingale’s classic text Notes of Nursing amply demonstrates, over the past 150 years, nurses have been just as concerned with fulfilling their ethical responsibilities associated with promoting the wellbeing and welfare of people in nursing, health care and other related domains as they are today (see also Chapter 2‘Be good women but do not bother with a Code of Ethics’ in Johnstone 1999a).

Building on its rich and distinctive history, nursing ethics today has arguably never been more informed, more developed or more visible. Neither has it had more authority as a political discourse in both health care and social domains to challenge the status quo, nor a greater capacity to fulfil its task of promoting human welfare and wellbeing. There exists a plethora of literature on the topic (which is growing day by day), and opportunities to research and to study nursing ethics abound. Accordingly, nurses are now better prepared and better positioned than they perhaps have ever been to fulfil one of their most stringent moral responsibilities, namely, to advocate the health and welfare interests of the individuals, groups and the communities they serve.

Ironically, the development of nursing ethics and the improved capacity of the nursing profession generally to engage in people advocacy is at risk of leading to less activism, rather than more. One reason for this, as I have discussed elsewhere, is that we have entered into an age of ‘moral paradox’: on the one hand there exists an unprecedented moral activism in the world, with various people fighting all sorts of battles on a whole range of moral causes (such as the right to life, the right to die, and so forth). On the other hand, there exists an unprecedented moral passivism — imported, paradoxically, by the moral activism of the times (Johnstone 2002b). The moral paradox, in this instance, lies in the reality of individuals subscribing to the highest moral ideals yet never lifting a finger to help another human being or to support in a personal and individual way reform movements aimed at improving the status quo (Hoff 1982). Equally ironical is the moral complacency (another form of moral passivism) that seems to be emerging among some health care professionals who believe that because they have ‘done’ ethics (meaning, have studied ethics as part of a formal professional or continuing education program) they have discharged their moral responsibilities to stakeholders and need take no further action as morally accountable professionals.

The nursing profession is at no lesser risk than are others of being sucked into the vortex of moral passivism. Those participating in debates on ethical issues in nursing and health care thus must take care to ensure that their knowledge and words are distilled into action with desirable outcomes, and not left standing merely as substitutes for action and outcomes. As Florence Nightingale once cautioned in a letter to a friend:

Nurses should never underestimate their capacity, as individuals, to achieve good moral outcomes in the contexts in which they live and work (Johnstone 2002a, 2008). Importantly, nurses also need to be aware that taking moral action need not necessarily involve some ‘great startling heroic deed’ on their part, and may include ‘simple’ acts such as showing kindness and compassion towards another, or merely questioning why something is being done one way rather than another. Although ‘basic’, these latter acts often stand as catalysts for change in people and the environments in which they live and work.

Nurses can also achieve a great deal collectively. Indeed, collective action can often be more powerful and more successful than individual action. One reason for this is that collective action can help to reduce the vulnerability of individual nurses who, when acting alone, might otherwise be ‘martyred by the system’ and consequently left to carry a disproportionate burden of loss that others, who merely look on as morally passive bystanders, do not have to suffer (Johnstone 2002a, 2008).

In their book From Silence to Voice: What Nurses Know and Must Communicate to the Public, Buresch and Gordon (2000) challenge nurses to ‘envision how things would be if the voice and visibility of nursing were commensurate with the size and importance of nursing in health care’. Taking up this challenge, we might also envisage how things would be if the volition (acts of will) of nursing — in addition to its voice and visibility — was commensurate with the size and importance of nursing in health care.

In 2003, the ICN Florence Nightingale International Foundation (FNIF) awarded Carol Etherington, a registered nurse from Nashville, Tennessee (in the United States [US]), the International Achievement Award for her outstanding work with some of the world’s most desperate populations, notably people living with the aftermath of war and natural disaster and for whom she had designed and implemented community-based support programs ( International Nursing Review 2003). The International Nursing Review reports that in selecting Ms Etherington for the award, the FNIF Board acknowledged ‘the international impact of her outstanding contribution in advocacy for vulnerable and victimised populations’. Her work within the US in child abuse, ethics and human rights was also identified as being extremely important ‘since these are topics on nursing’s agenda worldwide’. Etherington is also credited with forging the path for nursing ‘into criminal justice and social services by initiating programs serving victims of crime, citizens in crises, social and rescue personnel, and victims of disasters’ ( International Nursing Review 2003).

Etherington, other recipients of the FNIF Award (e.g. Margaret Hilson [1999], Susie Kim [2001] and Anneli Eriksson [2007] — see http://www.fnif.org/awards.htm), and others like them stand as moral exemplars on the horizon of moral possibility across a range of challenging circumstances, including those that are overwhelming and beyond human control. Etherington’s story, like the stories of others before and after her, is a story not only of the power of one but the power of all to make a difference to the world and to the lives of people who live within it — even when the odds are stacked high against them.

We may not all be able to engage in the exemplary levels of activism and advocacy that recipients of the ICN FNIF and other merit awards deservedly receive. However, neither can we rest content that just because others are undertaking such work, nothing further needs to be done on our own part and accordingly we can slip silently to the sidelines of human endeavour and passively watch as the world goes by. So long as we choose to work and interact with other human beings in our capacity as nurses and as moral human beings, it is fundamentally within our power and indeed our responsibility to act in ways ‘which bring results’ that, even when ‘small’ and seemingly insignificant, may nevertheless have a significant impact on the welfare and wellbeing of others. The challenge before us is to accept this power and to use it wisely and effectively to enable morally just outcomes to be achieved in the world of human affairs. If we elect not to take up this challenge then we risk failing not only ourselves, but the individuals, groups and communities that have come to rely on the nursing profession for care and its global promise to ‘walk the talk’ of respecting human rights, promoting health, preventing illness, restoring health and alleviating suffering — particularly among vulnerable populations.

The nursing profession has never been in a better position professionally, socially or politically to take the action necessary to achieve its moral goals. By using its position and moral capacity to achieve just outcomes in the contexts in which nurses work, the nursing profession will not only demonstrate the fulfilment of its responsibilities to the individuals, groups and communities it aims to serve, but will provide an important example of what it means to be moral in a world that is increasingly willing to allow rhetoric rather than reality, and words rather than deeds, to stand as the hallmarks of moral responsibility and enterprise.