A systematic approach to ethical decision-making for nurses

Throughout their careers, nurses, nurse practitioners, and other nursing professionals will encounter challenging situations at work that present ethical dilemmas. Deciding what to do in these situations can cause significant stress, as the appropriate course of action can vary depending on each unique set of circumstances. This article reviews a model that nursing professionals can use as a guide to help them gain a better understanding of conflicting issues and navigate ethical dilemmas.

Nurses are well aware of patients’ rights, such as the right of patients for self-determination (the right to make decisions about their own care). This right has even been codified in law as a result of the Patient Self-Determination Act (PSDA) of 1991, which requires healthcare agencies receiving Medicare and Medicaid reimbursement to provide information about advance directives. Patients’ rights, like self-determination, also play a role in ethics. For example, Provision 1.4 of the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (the Code) states that the patient has a right to self-determination.

In the clinical setting, ethical conflicts related to self-determination and other ethical principles are not unusual. Consider these possible scenarios: A family member disagrees with an advance directive that a patient completed now that the patient is unable to speak for themself. A patient declined to receive a potentially life-saving treatment even after receiving information about the process. A nurse wonders if a patient has received enough information from the physician to truly give informed consent. How can these types of ethical dilemmas be resolved? Taking a systematic approach can help you navigate toward a decision, but first it is useful to understand how legal issues relate to ethical principles.  

Legal responsibilities

Even though the Code relates to ethics and not the law, attorneys could turn to it for evidence that a nurse’s behavior did not meet the standard of care. For example, the Code states, “Nurses preserve, protect, and support those rights by assessing the patient’s understanding of the information presented and explaining the implications of all potential decisions.” If you fail to act when you think a patient did not receive enough information about a treatment decision, you could be held liable.

In addition, keep in mind that principles such as self-determination and patient autonomy applies not only to end-of-life care but to all treatment decisions. Therefore, going against a patient’s wishes could put you in legal jeopardy. For example, drawing blood from a patient who states he does not want lab work done could be considered battery.

To help avoid legal peril, use a systematic approach to making ethical decisions, based on ethical principles (see Key ethics principles). One such approach is a framework for ethical decision making from the American Counseling Association (ACA). While written for counselors, the framework outlines seven steps any healthcare professional can use to approach ethically ambiguous situations:

#1. Identify the problem.

To identify the problem, you first need to gather information related to the situation. Focus on facts, not assumptions. Consider whether the issue is related to yourself and what you are doing (or not doing) or is related to the patient or the patient’s loved one and what they are doing or not doing. For example, in the case of a young teenager who has not been informed he has brain cancer at the request of his parents, an ethical issue relates to the dynamics of the parents not wanting the diagnosis to be shared and the healthcare professionals who must consider the impact on the patient.

Be sure you are truly facing an ethical problem and not a clinical, legal, or professional one or a combination. Other considerations include whether the issue is related to technology (e.g., mechanical ventilation) or organizational policy. For example, legal statutes and organizational policy related to removing a patient from life support could conflict with what you see as the right ethical path. If there is any element of a legal issue involved, be sure to consult your organization’s risk management or legal department, or an attorney.

#2. Apply the code of ethics. 

Once you have identified the problem, turn to the Code. In some cases, the answer may be there. For example, a patient gives you a computer tablet as a thank-you gift. You had wanted to purchase a new tablet to replace your old one, but you are unsure if you should accept the gift. Provision 2.4 of the Code states, “Accepting gifts from patients is generally not appropriate.” The provision goes on to state that one factor to consider is the value of the gift. The cost of a tablet means you should decline the gift. (In addition, your organization likely has a policy that prohibits gifts from patients.)

You should also consider other relevant codes that might apply. For example, the American Association of Nurse Anesthetists has their own Code of Ethics for the Certified Registered Nurse Anesthetist.

If the issue is not resolved by codes of ethics, you will need to move on to the next step.


#3. Determine the nature and dimensions of the dilemma. 

To accomplish this task, analyze the dilemma in terms of ethical principles. Determine which principles apply and which have priority in this case. For instance, a patient with a history of chronic pain is asking for an early refill of his narcotic prescription. Granting the prescription might meet the principle of beneficence in the short term by providing pain relief but could violate the principle of nonmaleficence by putting the patient at risk of substance misuse. 

As part of your analysis, consider consulting the literature to ensure current, evidence-based practice. Thinking and consulting with colleagues or managers can also help you see other points of view. Another excellent resource is your organization’s ethics committee. In certain situations, you may even want to consult with your state or national professional association for input.

#4. Generate potential courses of action. 

This is the time for brainstorming ideas for actions to take. Write the ideas down without taking time to consider whether they are viable. Having another colleague or your manager help you with this step is a good idea. 

#5. Consider the potential consequences of all options and determine a course of action.

Now you should evaluate the potential courses of action you identified. Consider each option in the context of the information you have and evaluate the positive and negative effects of the option in relation to ethical principles you have identified. You will also want to evaluate each action for the potential effects on you, the patient, and any others who will be affected, for example, the patient’s family or the organization. It may be helpful to write a list of pros and cons for each option.

Toss out options that are problematic and take a closer look at the remaining ones, ultimately picking the one that best fits the situation.

#6. Evaluate the selected course of action.

Once you have chosen a course of action, test it to determine if it truly is the best option. The three “tests” are justice, publicity, and universality:

  • To apply the test of justice, consider your own sense of fairness and whether you would treat others the same in the situation.
  • To apply the test for publicity, ask if you would want your behavior reported in the media.
  • And to apply the test for universality, consider whether you would recommend the same course of action to another nurse.

If your option does not fulfill all three tests, return to the start of the process. You may find that you did not properly identify the problem. If your choice met the tests, you are ready to move forward.

#7. Implement the course of action.

Know that just because you feel the action is the right one does not mean it will be easy to carry out. You may need to engage in stress reduction techniques before and after the action.

Once the action is completed, determine if the result was what you anticipated. This is a good opportunity to learn how be more effective in making ethical decisions in the future.


A proactive approach  

Ethical dilemmas can cause significant distress, even when managed appropriately. To reduce distress, follow a step-by-step approach to making decisions. Consult your manager or your organization’s risk management or legal department for assistance. And if there are significant legal concerns involved, it may be useful to consult an attorney before proceeding.

Key ethics principles
Below are key ethical principles nurses should know:

  • Autonomy. This addresses self-determination, allowing the person the freedom of choice and action. It is important to help patients understand the implications of their decisions and to ensure that family members not pressure patients to make a choice. In addition, if you feel a patient is not capable of making a decision, follow organizational policy to determine an appropriate surrogate decision-maker.  
  • Beneficence. This refers to “doing good.” Although this principle seems simple, it is not always easy to determine what is “good” in an ethical dilemma. Beauchamp and Childress state that beneficence includes protecting and defending the rights of others, preventing harm from occurring to others, removing conditions that will cause harm to others, helping people with disabilities, and rescuing persons in danger.
  • Nonmaleficence. This principle refers to not causing harm to others, including not inflicting intentional harm and not engaging in actions that risk harming others. One way to address this principle is to weigh potential harm against potential benefits. The goal is to select interventions that create the least amount of harm to obtain the most beneficial outcome. 
  • Fidelity. Honoring commitments is the focus of fidelity. Fidelity incudes acting with caring and being honest; patients need to feel they can trust you. For example, if a patient does not want to share her advanced cancer diagnosis with family members, you should honor that wish.
  • Justice. Justice does not mean treating everyone the same. Rather, it means treating a person in a way that meets his or her individual needs. Examples include providing education materials in patients’ preferred language and offering free flu shots to those in need.

By Georgia Reiner, MS, CPHRM, Risk Analyst, NSO

American Association of Nurse Anesthetists. (2018). Code of Ethics for the Certified Registered Nurse Anesthetist. www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/code-of-ethics-for-the-crna.pdf
American Nurses Association. (2015). Code of Ethics with Interpretive Statements. www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only.
Beauchamp T.L., & Childress J.F. (2019). Principles of Biomedical Ethics, 8th edn. New York, NY: Oxford University Press;.
Beemsterboer, P. (2018). Ethics in dentistry: Part III – Ethical decision making. DentalCare.com. www.dentalcare.com/en-us/professional-education/ce-courses/ce546/ethical-decision-making-models
Davis, C. (2018). Ethical decision-making. Nurs Made Incredibly Easy, 16(2), 4-5. https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2018/03000/Ethical_decision_making.1.aspx
Forester-Miller H., & Davis, T.E. (2016). Practitioner’s Guide to Ethical Decision Making (rev. ed.). American Counseling Association. www.counseling.org/docs/default-source/ethics/practioner-39-s-guide-to-ethical-decision-making.pdf?sfvrsn=f9e5482c_10
Teoli, D., & Ghassemzadeh, S. (2019). Patient self-determination act. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK538297/

Disclaimer:The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.

This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

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A systematic approach to ethical decision-making for nurses

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