As a nurse, you probably face ethical dilemmas that challenge your decision-making and leave you feeling stressed and alone. Even worse, there's seldom an easy answer to the many sad or difficult situations you encounter in healthcare. So, is it possible to make navigating ethical dilemmas in nursing easier? Yes! You just need to prepare for different situations mentally and professionally.
Defining Ethical Dilemmas in Nursing
But first, what is an ethical dilemma? The best way to understand the term is to look at each word separately.
Ethics involves morals and knowing what is right or wrong in a situation. We all have personal ethics based on our values, culture, upbringing, and individual choice. In nursing, the American Nurses Association (ANA) governs a Code of Ethics for Nurses they expect you to follow.
A dilemma occurs when a nurse has two or more options, but none provides a good alternative.
An ethical dilemma in nursing is a situation in which one or more options violate our personal or professional ethics. This confusing situation makes it difficult to know which choice to make or what direction to follow.
4 Ethical Nursing Principles
It helps to take a step back and look at the four ethical nursing principles that underpin the Code of Ethics for Nurses and provides a framework for making decisions.
1. Autonomy: Patients are free to make their own healthcare decisions—based on their values, culture, and beliefs.
2. Beneficence: Nurses are morally obligated to do good for the patient and not cause harm, regardless of their personal opinions or values.
3. Justice: Nurses are to treat their patients "justly," meaning that their age, culture, economic status, sexual orientation, or religion shouldn't impact the quality of care.
4. Non-maleficence: Nurses give safe care and avoid actions that might cause harm.
However, even this doesn't completely relieve the tension of an ethical dilemma because your patient's decision not to take a life-saving treatment (autonomy) often conflicts with beneficence, your obligation to do good and not cause harm.
How to Recognize an Ethical Dilemma
Feelings of anxiety, burnout, and moral distress often make nurses aware of an ethical dilemma. Some situations clearly present ethical conflict, whereas others develop over weeks or months. Check out this article on moral distress and burnout in the ICU to get a better handle on it.
Common Reasons for Ethical Dilemmas
One way to prepare for ethical dilemmas is to know some of the causes. It gives you mental time to prepare before being faced with ethically challenging and gut-wrenching options. I’m sure you can add many more, but here are a few common reasons that cause ethical dilemmas:
Life and Death Decisions
Patient Care that Challenges Personal Beliefs
Parents Letting Children Make Healthcare Decisions
Parents Making Questionable Decisions for Children
Navigating Ethical Conflict in Nursing
There are no pat answers to resolving ethical conflict in nursing, but here is a three-pronged approach to help you prepare mentally and professionally.
1. Know that your moral and ethical values help you recognize and deal with ethical dilemmas. Don't wait for a challenging situation to develop before doing an internal audit and analysis.
2. Know your professional nursing ethics and professional responsibilities. Buy a Code of Ethics for Nurses. The nine provisions guide ethical decisions.
3. Familiarize yourself with Utilitarianism and Deontology—two ethical nursing theories that direct healthcare decision-making.
Utilitarianism believes in offering the greatest benefit for the greatest number of people—sacrificing one for the health of many. Deontology, on the other hand, believes that healthcare professionals shouldn't cause harm to any patient regardless of the consequences. The solution to many ethical dilemmas is between these two theories.
Real-life Nursing Ethics Cases
Sometimes, working through a few nursing ethics cases can help you understand the process. Here are three real-life cases to ponder:
1. Obeying a Physician's Order vs. Patient Autonomy
Scenario: Zoë, 16 years old, is admitted to a surgical unit before having knee surgery. She refuses to give a urine sample after learning it's to determine pregnancy. She tells the nurse that she's religious and has never had sex. The physician orders an HCG to be added to her blood work—so that she won't know she's being tested for pregnancy.
Ethical dilemma: The nurse feels conflicted between following the physician's orders and upholding the patient's request.
What should the nurse do? Provision 3 of the Code of Ethics states that the nurse is responsible for advocating for the patient's rights and, therefore, must refuse to add the blood work without the patient's knowledge. If the physician insists on the nurse following the orders, the nurse should refer the situation to the unit manager.
2. Personal Values vs. Parent's Choice for Their Baby With Seizure Disorder
Scenario: After speaking with the physician, the parents of an 8-month-old infant diagnosed with a rapidly progressing neural disease, early infantile epileptic encephalopathy (EIEE), decided to have a feeding tube inserted. This procedure will increase the life expectancy from two to five years.
Ethical dilemma. The nurse has seen babies with this illness before. Despite medications, they seizure almost continuously, arching backward and sometimes shrieking in pain. The nurse is concerned that the parents don't know how much suffering their child will incur. The nurse would certainly not put their own child through this.
What should the nurse do? The child's legal parents are entitled to make medical decisions. Although these are valid concerns, nurses cannot impose their opinions or values on the family. The nurse should speak to the physician about their problems. The physician can alleviate the nurse's feeling of responsibility by acknowledging that their conversation with the family covered these issues. If the nurse feels this situation is causing personal anxiety, they might ask their manager to change their work assignment.
3. Religious Values vs. Healthcare Interventions
Scenario: A Jehovah's Witness mother with five small children is admitted to the emergency department, hemorrhaging from a miscarriage. Based on her religious beliefs, she refused a blood transfusion.
Ethical dilemma: The patient's wishes go against the ethical principle of doing good and not harm—autonomy vs. beneficence.
What should the nurse do? Patients are free to make their own healthcare decisions. It’s emotionally challenging for healthcare workers not to give life-saving treatments to patients. However, nurses must follow their wishes if the patient is competent, alert, and oriented. Document every detail, and work quickly with the other medical team members to take other life-saving measures, such as massaging the uterus, giving fluid expanders, and preparing the operating room for a dilation and curettage (D & C).
Whatever the situation, it doesn't work to ignore an ethical dilemma.
Coping With Ethical Stress in Nursing
Ethical dilemmas don't go away, and nurses who ignore them may find themselves in one of these situations:
Burnout: Unresolved ethical conflict causes burnout. The unrelenting stress may cause physical symptoms such as headaches, panic attacks, and difficulty sleeping. Nurses suffering from burnout make more medical errors and compromise patient safety.
So, how do you take care of yourself? The best place to begin is to recognize and acknowledge the reasons for your burnout. Speak with your manager about taking time off to recharge. Get lots of exercise. Eat healthy. Hang out with friends.
Legal Trouble: Ignoring an ethical dilemma can land a nurse in legal trouble. The family may sue a nurse who gives a treatment that the patient has refused. Nurses should seek help from their manager and ethics committee for situations they need help with.
Job and/or Licensure Loss: Nurses who don't follow professional ethics laid out by their association risk losing their jobs and their licenses. If nurses don't receive support from their managers or employers, they should contact their association and union for direction.
Ethical dilemmas will always exist because nurses and patients have different priorities and goals. Navigating these dilemmas can be tricky, and nurses must mentally and professionally prepare themselves to handle each situation. Following the four ethical nursing principles and the Code of Ethics for Nurses provide some solutions. However, a few ethical concerns must go to ethical committees for further direction and support.
Alice Blackmore, MN, RN, Content Writer
Alice is a registered nurse and healthcare writer. She has more than 20 years of nursing experience, which ranges from labor and delivery to long-term care, with pediatrics, community nursing, and critical care sandwiched in the middle.