A Systematic Approach to Ethical Decision-Making for Nurses

December 2022

This article, from the Nurses Service Organization, reviews a model that nurses can use to better understand 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.)

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 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.