The first and only substantive work on the obligation of duties to self in the nursing literature is Andrew Jameton’s essay “Duties to self: Professional Nursing in the Critical Care Unit.”³ Jameton notes that some philosophers, such as John Stuart Mill, have denied “that it is meaningful to talk of duties to self,” but that others, including Aquinas, Kant and Hume “assert the meaningfulness of speaking of duties to oneself.”⁴ The arguments against a notion of duties to self center on our inability to enforce such duties, specifically, that it is not meaningful to speak of selfcoercion and secondly that we cannot release ourselves from such duties. Arguments for a notion of duties to self emphasize that while I cannot force myself to meet such a duty, even so, I am answerable for not meeting them and that duties to self are an instrumental good, that is, a good that serves to support my duties to others. Note that duties to self differ from self-centeredness or entitlement in that
they specifically support my moral duties to others. The strongest argument for a notion of duties to self resides in the concept of universal obligations. If an obligation applies to everyone, then I am not exempt from the collective “everyone,” and those duties apply to myself as well. Immanuel Kant’s second formulation of the categorical imperative (his rule for moral rule-making) makes clear the inclusion of one’s self in the universal: “Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means” [italics added].⁵

The nursing ethics literature from the 1800s to the present has affirmed an obligation of duties to self. One of the earliest such references is found in Trained Nurse and Hospital Review, July 1889. The article by “H.C.C.” (an otherwise unidentified superintendent of a training school in Boston), is entitled “Ethics in nursing: A nurse’s duties to herself: Talks of a superintendent with her graduating class.”⁶ The focus of the article is on rest and bodily care as essential to the health of the nurse for the sake of the ability to meet her duties to patients. (In that period, nurses were exclusively female.) Particular concern is directed toward the dedicated, energetic nurse who may overextend and risk personal health in the course of care-giving. H.C.C. writes: “Please remember I am only speaking to the good nurses—the enthusiastic one—poor nurses, lazy nurses, have no temptation to overwork themselves. They may die of indigestion but they will not die of exhaustion.”⁷ Many of the early nursing ethics books echoed an emphasis upon duties to self. Isabel Robb’s oft reprinted Nursing Ethics: For Hospital and Private Use (1900) places considerable emphasis on a range of duties to self.⁸

This emphasis on self-regarding duties has for decades remained prominent in nursing ethics literature, including the earliest codes. The Tentative Code of 1940, one of the early unadopted codes for nursing, includes a section on the nurse’s responsibilities to herself. It states: “A nurse is to keep herself physically, mentally, and morally fit, and to provide for spiritual, intellectual, and professional growth. She should institute savings plans which will bring her financial security in her old age.”⁹ While the emphasis on duties to self persists in the nursing literature, especially in textbooks, it departs from the later codes. The incorporation of a provision on self-regarding duties in the present code is indeed a “reappearance” rather than something “new.”

This section introduces this duty and grounds it in the self-inclusiveness of universal duties: what I owe to others as moral duties, I likewise owe to myself as a moral duty. Without so stating, this would mean that all of the provisions that apply to
patients would also apply to oneself. For instance, Provision 1 states that “the nurse, in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual.”¹⁰ Self-respect, then, becomes one of the many duties owed oneself.

The focus of the interpretive statement is on explaining the several distinguishably different areas of concern. Jameton has identified three such aspects of duties to self: integrity, self-regarding duties, and identity. Identity refers to the coherent integration of one’s personal and professional identity—what I am morally as a person, I am morally as a nurse. According to Jameton, identity includes concerns for maintaining ideals, the meaningfulness of work, expression of one’s opinion, concern for wrongs committed by others, and participation in moral judgment in the work setting. Self-regarding duties refers to “duties [that] have a content that affects or applies to oneself primarily,” here competence is of specific concern. Integrity includes wholeness of character, attention to one’s own welfare or self-care, and emotional integrity reliant upon maintaining relational boundaries.¹¹ The current provision is indebted to Jameton for his pioneering work, and incorporates his three aspects in three somewhat different divisions: professional growth and maintenance of competence, wholeness of character, and preservation of integrity.

Previous codes, such as the Suggested Code of 1926 and the Tentative Code of 1940, have included a responsibility for ongoing professional growth. The Suggested Code states:

Though the context is that of professional growth as a duty to self, it does not so much discuss professional growth as it does how one might go about growing professionally.

The Tentative Code of 1940 is not quite so specific; it declares a “requirement of continuous study and growth” and a duty for the nurse “to provide for spiritual, intellectual and professional growth,” as noted above.¹³ In several codes, such as that of 1950, the nurse is responsible for “continued reading, study, observation,
and investigation,” not strictly as a duty to self, but rather as a duty to the profession in order that the social/professional status of nursing, and the status of the individual nurse as a professional, may be maintained.¹⁴ Notice, however, that it moves beyond continued study and reading for self-development, or even to better serve the patient; instead, it casts the duty in terms of maintaining the stature of nursing as a profession, as well as the social prestige of nursing. Nursing has, of course, struggled for years for the social recognition accorded professions. The Tentative Code even opens with the assertion “Nursing is a profession,” and then goes on to defend that assertion with a sizable amount of material that is not actually appropriate to a code of ethics.¹⁵ Here, the concern is for the profession and its professionalism, not for the nurse, so it could be argued that, in this particular statement formulation, it may not be a duty to self.

The emphasis upon professional growth as a duty to self shifted over the years in two ways. First, it shifted from a duty to self to a duty to the profession for the sake of the profession. Second, it shifted in the direction of an increasing concern for competence, not only for the sake of the profession, but also for that of the patient as well. Though they have been used as if interchangeable, “professional growth” and “competence” are not the same. Competence is the rock bottom level of acceptable practice, the level below which no practitioner should fall. Professional growth moves the nurse beyond mere competence, as a minimum standard of practice, toward excellence and is thus directed toward an ideal of practice. The Code of 1985 merges professional growth and competence and their ends, stating that: