FIRST INTERNATIONAL CODE OF ETHICS FOR NURSES

PRIMER CÓDIGO INTERNACIONAL DE ÉTICA EN ENFERMERÍA

ABSTRACT

Objective:

to historicize the approval of the First International Code of Ethics for Nurses and analyze its 14 articles and their relevance to the historical and current context.

Method:

this is a historical and social study, with a qualitative approach. The sources were composed of official publications of the International Council of Nurses and reports of activities developed during the X Quadrennial Congress in 1953. A document review was carried out, involving two processes: the external criticism, regarding the authenticity of the document, and the internal criticism, which consists in the careful reading of the text, in an effort to interpret it.

Results:

the first International Code of Ethics for Nurses discusses the nurses’ responsibilities in their professional and personal life to guarantee the social recognition of this professional, as well as an ethical performance, encompassing the following aspects: the nurse’s commitment to the care provided and the valuation of professional and personal relationships, involving physicians, patients, and the community.

Conclusion:

as this code would have to meet the needs of nurses in the several cultures, religions, customs, and laws and regulations of the continents, it was based on universal principles and concepts, such as respect for life, dignity and human rights, without discrimination of any kind. In this direction, the 1st International Council of Nurses Code of Ethics set out to be a universally accepted document in its fundamental ethical principles, regarding the patient and the relationships between the nursing team, and physicians, as well as other professionals.

DESCRIPTORS
Nursing; History of nursing; Ethics; Ethics, Nursing; Codes of ethics

RESUMEN

Objetivo:

historizar la aprobación del Primer Código Internacional de Ética en Enfermería y analizar sus 14 artículos y su relevancia para el contexto histórico y actual.

Método:

se trata de un estudio histórico-social, de abordaje cualitativo. Las fuentes estuvieron compuestas por publicaciones oficiales del Consejo Internacional de Enfermeras y por informes de actividades desarrolladas durante el X Congreso Cuadrienal, en 1953. Se procedió al análisis documental, que está compuesto por dos procesos: la crítica externa, que se refiere a la autenticidad del documento; y la interna, que consiste en la lectura cuidadosa del texto, buscando interpretarlo.

Resultados:

el primer Código Internacional de Ética en Enfermería discurre sobre las responsabilidades de la enfermera en su vida profesional y personal, como formas de garantizar el reconocimiento social de esta profesional, además de una actuación ética, englobando los siguientes aspectos: el compromiso de la enfermera ante la asistencia prestada y la valoración de las relaciones profesionales y personales, involucrando a los médicos, pacientes y la comunidad.

Conclusión:

como este código tendría que atender a las necesidades de profesionales de la Enfermería en las diversas culturas, religiones, costumbres y legislaciones de los continentes, se basó en principios y conceptos universales, como el respeto a la vida, a la dignidad y a los derechos humanos, sin discriminación de ningún tipo. En esta dirección, el 1º International Council of Nurses Ethics propuso ser un documento aceptado universalmente en sus principios éticos fundamentales respecto al paciente, a las relaciones entre el equipo de enfermería y a los médicos, así como otros profesionales.

DESCRIPTORES
Enfermería; Historia de la enfermería; Ética; Ética en enfermería; Códigos de ética

RESUMO

Objetivo:

historicizar a aprovação do Primeiro Código Internacional de Ética em Enfermagem e analisar seus 14 artigos e sua relevância para o contexto histórico e atual.

Método:

trata-se de um estudo histórico-social, de abordagem qualitativa. As fontes foram compostas de publicações oficiais do Conselho Internacional de Enfermeiras e dos relatórios das atividades desenvolvidas durante o X Congresso Quadrienal, em 1953. Procedeu-se à análise documental, que comporta dois processos: a crítica externa, que se refere à autenticidade do documento, e a interna, que consiste na leitura atenta do texto, procurando interpretá-lo.

Resultados:

o primeiro Código Internacional de Ética em Enfermagem discorre sobre as responsabilidades da enfermeira em sua vida profissional e pessoal como formas de garantir o reconhecimento social desta profissional, além de uma atuação ética, englobando os seguintes aspectos: o compromisso da enfermeira frente à assistência prestada e a valorização das relações profissionais e pessoais, envolvendo médicos, pacientes e comunidade.

Conclusão:

como este código teria de atender a necessidades de profissionais da Enfermagem nas diversas culturas, religiões, costumes e legislações dos continentes, foi baseado em princípios e conceitos universais, como respeito à vida, à dignidade e aos direitos humanos, sem discriminação de espécie alguma. Nessa direção, o 1º International Council of Nurses Ethics propôs-se a ser um documento universalmente aceito em seus princípios éticos fundamentais, no que tange ao paciente e às relações entre a equipe de enfermagem e médicos, bem como outros profissionais.

DESCRITORES
Enfermagem; História da enfermagem; Ética; Ética em enfermagem; Códigos de ética

INTRODUCTION

The first International Code of Ethics for Nurses was approved by the Council of National Representatives (CNR) of the International Council of Nurses (ICN) on July 10, 1953. CNR is the maximum body of deliberations of this organization, which meets every two years, in different cities and countries. The ICN brought to Brazil this event and the X Quadrennial Congress, which took place, respectively, at the School of Nursing of the University of São Paulo (Escola de Enfermagem da Universidade de São Paulo - EEUSP), in the city of São Paulo, and at the Quitandinha Hotel, in Petrópolis, Rio de Janeiro.

The approval of this first Code of Ethics for Nurses happened at a time favorable to changes in the professional standards. Due to the cruel atrocities and experiments to which prisoners were subjected to in World War II, an international military court was created by the Allied Countries in the Second War to adjudicate political and military leaders of Nazi Germany. Prisoners taken to concentration camps were used in various types of brutal experiments, without any explanation of the practices or even the consent of the subjects. More than 20 physicians were accused and considered to be war criminals for such practices, many of whom were sentenced to death. These trials took place in the city of Nuremberg,1 in Germany, between 1945 and 1946.

In total, the so-called Nuremberg Code, as it became known, was approved with ten principles that dealt with the conditions for conducting research in humans, the relationship between the research subject and the researcher, emphasizing the need to obtain prior consent from the research subject, as well as the need to avoid human suffering, especially during the experimental researches.2 However, these principles approved in 1947 only became part of the doctor-patient relationship much later, in the 1960s and 1970s, through the Declaration of Helsinki,3 which was drafted and approved in 1964 by the 18th World Medical Assembly held in Finland. This Declaration has been revised and updated numerous times, and the 7th and last version was approved in October 2013 in Fortaleza, Brazil.

Later, in 1993, the Council for International Organizations of Medical Sciences (CIOMS), in cooperation with the World Health Organization (WHO), approved the International Ethical Guidelines for Biomedical Research Involving Human Subjects(updated in 2016).4 In Brazil, the Ministry of Health also approved Resolution No. 196 of December 10, 1996, with the guidelines and rules regulating researches involving human beings, updated by the new Resolution No. 466, of December 12, 2012.5

Long before the drafting of the Nuremberg Code, Jean Henri Dunant had already proposed the adoption of international treaties known as the Geneva Conventions,6 which constitute a series of treaties prepared in Geneva, Switzerland, defining rules for international laws relating to International Humanitarian Law. The conventions were the result of the efforts of Henri Dunant, after he witnessed the horrors of Battle of Solferino (1859), between Italy, France and Austria, in Italian territory, in which he was impressed by the abandonment and suffering of the wounded soldiers.7 These treaties define the rights and duties of persons, combatants or not, in time of war and, at the time, were unprecedented, consisted in the basis for international humanitarian law, which were created during four Conventions held in Geneva, between 1864 and 1949.6

The discussions of the First Code of Ethics for Nurses began long before its approval. The Nursing Ethics Committee9 of the International Council of Nurses, coordinated by Marjorie Eadon Craven, in July 1949, who reported receiving a copy of a resolution adopted by the WHO Executive Board on the establishment of an international code of ethics adopted by the National Academy of Medicine of France. This code had been submitted to 40 medical associations and was presented at the Annual General Meeting of the World Medical Association in London in October 1949. At the end of this WHO resolution, it was requested that its Director-General follow closely this work and bring the matter to the attention of the International Council of Nurses. This reference was a source of joy in the 1940s for the recognition of the connection between nurses and doctors in the exercise of their respective professions. On October 12, 1949, the World Medical Association8 indeed adopted the International Code of Medical Ethics, as also reported by Craven.9

In any case, the approval of this Code of Medical Ethics created new perspectives and encouragement to reach consensus on some general ethical principles that could be interpreted in each country in view of its laws and customs.

The Nursing Ethics Committee knew that, in order to pass an international code of ethics, it was necessary to consider the differences between countries where it should be applied - such as legislation, lifestyles, traditions, religion, cultures, customs, among other factors - and that it should be based on universal principles and concepts, such as respect for life, dignity and human rights, without discrimination of any kind. In the same way, it should address matters regarding the fundamental responsibilities of professionals that cover the person, society, professional practice, health team, and the profession itself.10

In the end, the Committee presented the report suggesting the approval of a proposal for an international code of ethics for nurses containing 14 articles. One of its terms stated that the fundamental concept that nurses believed in preserving human life, alleviating suffering, and promoting health was inherent in the code.9

The report of the Nursing Ethics Committee coordinated by the English nurse Craven, and the proposal for the International Code of Ethics for Nurses (ICE)11 were presented at the meeting of the Executive Office of the ICN. Finally, this Code was discussed and approved at the CNR on July 10, 1953, at the EEUSP, becoming a model and basis for nurses from each country to prepare their own Code of Ethics for Nurses.12

In the auditorium, today called Maria Rosa Pinheiro of EEUSP, the meeting of the CNR was held, whose participants unanimously approved the International Code of Ethics for Nurses, with its 14 articles. Haydée Guanais Dourado emphasized that “the universality of the moral law was the aspiration that guided many thinkers to find an independent philosophical basis for the moral code, recognizing the necessity of a method of ethics that would have universal acceptance of all the world’s religious currents”.13^{:151 - 52}And while “theological ecumenism was not victorious, the universal acceptance of the principles of ethics would be the closest victory to that”.13^{:151- 52} At the time, the ICN14 also published a detailed report of this event.

This first International Code of Ethics of the ICN was updated in 1973, followed by other minor adjustments or reaffirmations made by renowned experts from various countries in 2012,15 when, among other modifications, a preamble was included, stating that the need for nursing is universal, and that nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering.10

In addition to this Code of Ethics, the ICN has and keeps updated countless position statements - International Council of Nurses (ICN) Position Statements - on a number of specific issues, so that they can better guide their member organizations, nurses, and other professionals on complex, and often polemical issues, whether in the political, ethical, or professional field.

Therefore, this work aims to historicize the approval of the First International Code of Ethics for Nurses and to analyze its 14 articles and their relevance to the historical and current context, noting that in Brazil the Code of Ethics for Nursing Professionals (CEPE) was reformulated on December 6, 2017, pursuant to Cofen Resolution 564/2017.16 It is worth noting that this new CEPE emphasizes in its principles that “Nursing care is based on the knowledge of the profession and the human, social, and applied sciences and is performed by professionals in the social and daily practice of assisting, managing, teaching, educating, and researching”.16 Therefore, there is a broadening of the dimensions of professional action, in the present day, covering the technical and scientific and ethical and political dimensions.

However, it is interesting to note that this text was prepared and approved in the 1940s and 1950s. For this reason, it is incoherent to analyze it from the current view, since it was approved 65 years ago, and the world, the relationships, technology, and nursing itself have been modified several times. In the 1940s, 1950s, and 1960s, nursing was essentially religious, and obedience was a vow that all religious (mostly Catholics) of all congregations had to do and fulfill.

It is important to highlight that two approaches to ethics guided Nursing: the charitable ethics related to obedience and self-denial, which was rooted in the professionalization process of nursing, reinforcing duty and imposing professional sacrifice,¹⁷ and the philanthropic ethics, created by the State to serve the needy, but determining the caregiver’s behavior.18

In today’s world, the State and the profession seek secularization; however, in the social imaginary, this religious dedication of nursing remains.

METHOD

This is a historical and social study, with a qualitative approach. The sources analyzed were composed of official publications of the International Council of Nurses and reports on the activities developed during the X Quadrennial Congress in 1953. Access to the English reports was possible through the personal library of Doctor Taka Oguisso, who worked as a Nurse Consultant and later as Deputy Executive Director at the International Council of Nurses from 1987-1997.

A document review was used to examine the documentation, which is based on the internal and external criticism of the document, using a set of techniques that makes it possible to articulate the data collected with the proposed object, being able to extract excerpts of the history of nursing.19

RESULTS

Prior to the adoption of the International Code of Ethics for Nurses, the profession had some “codes”, so to speak, that dealt with professional ethics. Among them, we can mention the work “Practical Norms of Catholic Deontology - Directory of Religious and Catholic Nurses”,20 published in 1936 in Brazil, after being approved at the International Congress of Catholic Nurses, held in the same year by the Roman Catholic Church. This book contains general guidelines on cooperation in certain medical and hospital procedures. It should be noted that, up to the 1950s and 1960s, there was a very large proportion of religious nurses, from the most different congregations and institutes, working in Brazilian hospitals.

It is also important to mention the Nightingale Pledge (NP), considered a modified Hippocratic oath that was written by the American nurse Lystra E. Gretter, with the collaboration of the Committee of the Farrand Training School for Nurses of Detroit-USA, in 1893.21

As previously mentioned, the ICE was approved in 1953, during the X Quadrennial Congress of the International Council of Nurses in Brazil. Its content was published in the official journal of the ICN in the same year and later published in the Annals of Nursing in Portuguese (Chart 1), also in 1953.11

Chart 1 -
Content of the First International Code of Ethics for Nurses.

1. Nurses have three main responsibilities: to preserve life, to alleviate suffering, and to promote health.

2. Nurses shall always maintain the highest standard of nursing practice and professional conduct.

3. Nurses shall not only be able to practice at all times, but also maintain their knowledge and skills at a consistently high level.

4. The religious beliefs of the patient should be respected.

5. Nurses shall keep secret all personal information that is entrusted to them.

6. Nurses recognize not only the responsibilities, but also the limitations of their professional duties; only in emergency situations they advise or treat without medical prescription, reporting them to the doctor as soon as possible.

7. Nurses must follow medical orders intelligently and loyally and refuse participation in situations that are in disagreement with ethics.

8. Nurses shall maintain the trust the public places on the doctor and other members of the health care team. Professional incompetence or lack of ethics on the part of one of these members shall be reported only to the competent authority.

9. Nurses have the right to a fair remuneration and must only accept the payment set forth in the real or implicit contract.

10. Nurses shall not allow your name to be used in advertising for commercial products or in any form of personal advertisement.

11. Nurses shall cooperate with their colleagues and members of other professional groups and shall maintain harmonious relationships with them.

12. Nurses, in their private life, must respect personal rules of ethics that revert to the benefit of the profession.

13. Nurses, in their personal conduct, shall not consciously disregard the standards of conduct accepted by the community in which they live and work.

14. Nurses shall participate and share with other citizens and professionals the promotion of health programs to meet people’s health needs at the local, state, national, and international levels.

• Source: Code of Ethics for Nurses.11

DISCUSSION

The first article of this Code discusses the nurses’ responsibility to preserve life, alleviate suffering, and promote health. In this respect, it should be pointed out that the article is in line with the affirmation and the essence of responsibility, which deserve deep attention in relation to the professions rooted in health, such as, in this case, nursing. There was, however, a strong religious connotation on Nightingale Pledge, of 1893, which emphasized “woman’s purity” and the devotion of their acts.21

In the context studied, it is known that some orders and religious congregations, focused on the care of the sick, emphasized the vocation and charity in the nurse’s work, especially the religious nurse. It is known that they had greater power and autonomy when compared to the doctors. In the field of hospital care, the Church emphasized the need for excellent technical and vocational training, as well as the need to teach all religious-nurses and professional deontology (science of duty) courses. It was believed that such courses, which were to be taught by a theologian (or priest), with knowledge of the circumstances of the ministry of these religious women, would provide these nurses with insight into when and how to support physicians. Clearly, the Church told these religious women that they could not participate in certain medical conducts, such as abortion or euthanasia, or any other form of anticipation or procrastination of the death process. Even if the doctor ordered, in these cases the nurse should refuse to participate.20

The International Code of Ethics for Nurses, 1953, represents an attempt to untie this religious connotation of nursing practice, placing it at the professional level. However, at the time, there were still traces of religiosity not only in the care practices, but also in the social role of women.

The second topic of the ICE deals with professional conduct, which assumes that a set of attitudes should compose the professional work of the nurse to result, as stated, in the highest standard of nursing practice. In this context, it is important to emphasize the nurses’ responsibility in making decisions.22

The third topic of the ICE addresses the need for technical preparation and skills for nursing practice, emphasizing professionalization.

The fourth topic of the ICE addresses the need to respect patients’ religious beliefs as values that should be preserved and valued in the nurse-patient relationship. This ICN’ concern was far beyond its time, reverberating until today. In this direction, the values focus on the aesthetic configuration of care, which have been subject to historical and cultural variations. Thus, one of the consequences of these variations is the change of values and feelings, from motherhood, to professionalism and technique.23 Thus, the aesthetics of pre-professional care, structured in maternal values and feelings, is replaced through a deconstruction process, promoted by feminist and critical thinking during the last third of the nineteenth century and the first half of the twentieth century.24 This new aesthetic of professional care is progressively based on values and feelings promoted by rational technological thinking, science, and professionalism.25^-26

Confidentiality is the subject of the fifth ICE topic. This item is of great relevance nowadays, because “the unsatisfactory use of information by the actors involved in the care process can certainly make it difficult to offer an effective humanized and integral care”.27^:592 Privacy and confidentiality converge towards a sense of respect for the patient’s rights and, consequently, the professional duty to ensure the observance of this right, especially in the current context of care and management, where sometimes the own nursing professionals emphasize the technical (procedural) conduct, to the prejudice of relationships and being with others.

Topics 6, 7, and 8 state nurses’ subservience to physicians, and how they should behave in the field of inter-professional relationships, submitting and limiting themselves to the medical conduct. It is important to remember that this type of relationship was recommended in the 1940s, 1950s, and 1960s.

Topic 6 discusses the professional limitations that nurses must recognize in the exercise of their profession. The topic also points out that the nurses’ job may be performed without medical orders only in emergency cases, and this should be reported to the doctor as soon as possible. In topic 7, the topic of subservience is emphasized by the need to only refuse to fulfill a medical order when it is unethical. 28

Nurses currently enjoy greater autonomy in their decisions and in the arguing and questioning of medical decisions power, especially with the diffusion and implementation of the systematization of nursing care in different scenarios of practice.

Topic 8 states that the nurse should maintain the public’s trust in physicians and other members of the health care team, and that unethical conduct of other professionals should be exposed only to competent authorities. However, the International Code of Medical Ethics⁸ does not provide for, on a reciprocal basis, such treatment in relation to other health professionals.

Regarding the professionals’ remuneration, in topic 9, the Code of Ethics for Nurses determines that they are entitled to a fair payment and that only compensation agreed under contract should be accepted. This point is extremely relevant if we consider the overcoming of a charitable model of provision of nursing services, which preceded the professional model.29 In addition, in this item, one can consider that it is embedded the idea of not accepting tips or kickbacks for the service.

Topic 10 discusses the ethical prohibition on the use of nurses’ names in product advertisements and self-promotion. It should be noted that, during the Second World War, the image of the nurse was used to convey advertisements of various products to the consumer market, adding credibility to the brands.30

In topic 11 on professional relationships, the ICE emphasizes the importance of the relationships between members of the nursing team and other healthcare practitioners.

Topics 12 and 13 mention nurses’ private life and their behavior in the community in which they are inserted, that is, there is a concern with maintaining the same professional ethical standards in personal life, so that this is reflected positively in the profession. In addition, nurses shall not behave differently from the community where they live and work. It is observed here a concern with the status of the nurse’s profession, remembering that their actions could represent the society’s idea about nursing. As women, nurses move between the public and private universes, with strong control and discipline imposed on their conduct. Women are also active subjects in the process of increasing visibility, whose struggles and achievements have taken place in many fields and spaces throughout history.31

Topic 14 of the ICE suggests that nurses shall contribute to society and other professionals in order to meet health needs at all levels, from local to international, according to their range of action. There is a concern of the ICN with public health and nurses’ commitment to several areas and administration levels of health services in the countries (local, national, and international).

CONCLUSION

As such Code refers to a document drawn up in the 1940s and adopted in the early 1950s by world leaders at the time, to critically analyze it more than six decades later, it is of utmost importance to keep in mind the changes of concepts and customs prevalent at that time in relation to the present time. Thus, in view of the aspects presented on the first International Code of Ethics for Nurses, it was found that, in the 1950s, nursing was a work based not only on scientific principles, but also on ethical precepts, guiding the actions of professionals to ensure decision-making in line with human rights and citizenship.

As this code would have to meet the needs of nursing professionals from several cultures, religions, customs, and laws and regulations on the world, it was based on universal principles and concepts, such as respect for life, dignity, and human rights, without discrimination of any kind. In the same way, it should address questions about the fundamental responsibilities of professionals that cover the person, society, professional practice, health team, and the profession itself. In this direction, the 1st ICE intended to be a universally accepted document in its fundamental ethical principles, regarding the patient and the relationships between the nursing team and physicians, as well as other professionals.

On the other hand, a nurse’s “help” posture was observed so that the physicians could comply with the items in their code of ethics, which did not present reciprocity, since there was no mention in the International Code of Medical Ethics to the collective work with nursing and even with other healthcare practitioners.

The overcoming of a charitable model of provision of nursing services, which started the profession, addressed the remuneration, determining that nurses would be entitled to fair payment and that they should accept only the compensations agreed in contract.

The ICE stated that “the religious beliefs of the patient should be respected,” but this did not oblige nurses to be equally religious, although they should maintain an ethically personal conduct for the practice of nursing.

Therefore, it can be concluded that the first International Code of Ethics for Nurses enabled the profession to make achievements towards professionalization.

ACKNOWLEDGMENT

This study is a collaboration between researchers of the research group "History and Legislation of Nursing" (Brazilian National Council for Scientific and Technological Development - CNPQ/School of Nursing of the University of São Paulo - EEUSP).

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Publication Dates

• Publication in this collection
  18 July 2019
• Date of issue
  2019

History

• Received
  26 Apr 2018
• Accepted
  02 July 2018