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Ethics is the systematic study of what is right and good in human conduct. Morals are personal or group standards of right and wrong. Values are enduring beliefs about what is worthwhile. Law sets minimum enforceable standards; an action can be legal but unethical, or ethical but illegal.
Ethical dilemma — a situation in which two or more ethically justifiable choices conflict and choosing one means failing the other. A problem with one clearly right answer is not a dilemma.
Moral distress — the nurse knows the right action but institutional or other constraints prevent it. Moral uncertainty — the nurse is unsure which principles apply.
Bioethics applies ethics to health care and the life sciences; nursing ethics focuses on the nurse–client relationship, advocacy, and caring.
| Theory | Core idea | Key names | Nursing example | Weakness |
|---|---|---|---|---|
| Utilitarianism (consequentialism, teleology) | An act is right if its consequences produce the greatest good for the greatest number | Bentham, Mill | Allocating vaccine supply to save the most lives | Can sacrifice the rights of individuals or minorities |
| Deontology (duty-based) | An act is right if it follows a moral duty or rule, regardless of outcome; treat people as ends, never merely as means | Kant | Telling the truth even when the news is hard | Duties can conflict with no rule for ranking them |
| Virtue ethics | Focus on the character of the person acting — compassion, honesty, courage, prudence | Aristotle | "What would a good nurse do here?" | Gives little concrete guidance in a specific dilemma |
| Ethics of care | Morality grows from relationships, responsiveness, and attention to context and vulnerability | Gilligan, Noddings | Tailoring care to a frightened client's family situation | Can be seen as vague; risk of favoritism |
| Principlism | Apply mid-level principles (autonomy, nonmaleficence, beneficence, justice) and balance them | Beauchamp and Childress | Weighing a client's refusal against likely harm | Principles can conflict with no fixed ranking |
| Justice as fairness | Fair procedures and distribution, with priority to the least advantaged | Rawls | Fair criteria for intensive care beds | Abstract to apply at the bedside |
Act utilitarianism judges each act by its consequences; rule utilitarianism follows rules that generally produce the best consequences. Deontology is likewise divided into act and rule deontology.
| Principle | Meaning | Nursing example |
|---|---|---|
| Respect for autonomy | Respect the choices of a person with decision-making capacity | Giving full information and time before consent; honoring an informed refusal |
| Nonmaleficence | Do no harm; avoid or minimize risk and suffering (a negative duty) | Avoiding unnecessary painful procedures; preventing falls |
| Beneficence | Actively do good and promote well-being (a positive duty) | Treating an unconscious client in an emergency; providing comfort measures |
| Justice | Fair distribution of benefits, risks, and resources; equal treatment of equals | Fair ICU bed allocation; care without regard to insurance or social status |
Efficiency or cost is not one of the four principles — it is a managerial value.
Rules are more specific and action-guiding than principles; principles are broader and justify the rules.
Paternalism — overriding a person's wishes for their own good (beneficence overriding autonomy). "Weak" (soft) paternalism, applied when the person lacks capacity or has not made an informed choice, is more readily justified than "strong" paternalism against an informed, capable adult.
Principle of double effect — an act with a good and a foreseen bad effect is permissible if: the act itself is not wrong; only the good effect is intended; the bad effect is not the means to the good effect; and the good outweighs the bad. Example: titrating opioids to relieve dying clients' pain even though respiratory depression is possible.
Kohlberg (justice orientation; stages occur in an invariant sequence without skipping):
| Level | Stage | Reasoning |
|---|---|---|
| Preconventional | 1. Punishment and obedience | Avoid punishment |
| 2. Instrumental exchange (individualism) | "What's in it for me?" — fair deals | |
| Conventional | 3. Good boy/good girl (interpersonal conformity) | Seek approval; be seen as good |
| 4. Law and order | Obey rules to maintain social order | |
| Postconventional | 5. Social contract | Laws are agreements serving welfare and rights; can be changed |
| 6. Universal ethical principles | Conscience guided by universal principles of justice and dignity |
Gilligan (ethic of care) criticized Kohlberg for studying mainly males and ranking justice reasoning above care. Her levels: (1) orientation to individual survival (self-interest), (2) goodness as self-sacrifice (others' needs before one's own), (3) morality of nonviolence (care for self and others; avoid hurting anyone) — the highest level, with transitions between them.
The ANA revised the Code in 2025. It keeps nine provisions (reworded) and adds a tenth provision on global health. Paraphrased:
| Provision | Focus |
|---|---|
| 1 | Compassion and respect for the inherent dignity, worth, and unique attributes of every person |
| 2 | Primary commitment to the recipient of care — individual, family, group, community, or population |
| 3 | Trusting relationship; advocacy for the rights, health, and safety of recipients of care |
| 4 | Authority over nursing practice, with responsibility and accountability for that practice |
| 5 | Duties to self: dignity, a safe workplace, integrity, and professional competence |
| 6 | Establishing and improving the ethical environment of the work setting |
| 7 | Advancing the profession through knowledge development, standards, and policy |
| 8 | Collaborative relationships with other disciplines and the public |
| 9 | Social justice, eliminating health inequities, and human flourishing through policy and legislation |
| 10 | Participation in the global nursing and health community to promote human and environmental health |
The 2025 Code places greater emphasis on health equity, racism as a threat to health, workplace safety, and emerging technologies. The ICN Code of Ethics for Nurses (revised 2021) is the international counterpart.
| Situation | Principle or rule |
|---|---|
| Keeping a client's HIV status from staff not involved in care | Confidentiality |
| Not reading records of clients you are not caring for | Confidentiality and privacy |
| Explaining options and letting the client choose palliative care | Respect for autonomy (with beneficence) |
| Refusing an assignment beyond your competence, while not abandoning clients (notify the supervisor and hand off safely) | Nonmaleficence; Provision 4 accountability |
| Charting accurately, including your own errors | Veracity; accountability |
| Keeping a promise to return with pain medication | Fidelity |
| Reporting unsafe practice by a colleague | Provision 3 advocacy; nonmaleficence |
| Understaffing forcing unequal attention to clients | Justice |
| Giving objective information about a risky alternative therapy | Beneficence and nonmaleficence, while respecting autonomy |
Case 1. A nurse on a crowded unit must choose which of two clients receives the last available telemetry monitor. Framework: justice (fair criteria such as clinical need), not first-come or personal preference. Why: need-based distribution is the accepted clinical standard.
Case 2. A capable adult with diabetes insists on leaving against medical advice. Correct action: explain risks and alternatives, notify the provider, document the discussion and the client's understanding, and respect the decision. Why: respect for autonomy in a capable adult outweighs paternalism.
Case 3. A nurse posts a picture of a room "with no faces" and the caption "crazy day." A visible chart label identifies the client. Problem: breach of confidentiality and privacy; also a violation of hospital policy and HIPAA. Correct action: remove it immediately and report per policy.
Case 4. A nurse reasons, "I follow the policy because rules keep the hospital running." Stage: Kohlberg stage 4 (law and order), conventional level.
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