Ethical decision-making is a systematic, reasoned process for resolving dilemmas, similar to the nursing process. It does not guarantee a single "right" answer, but it makes the decision defensible, transparent, and respectful of everyone involved.

Key terms

• Ethical dilemma — two or more morally defensible options conflict
• Moral distress — knowing the right action but being constrained from taking it; can lead to burnout and moral injury
• Moral courage — acting on ethical convictions despite risk
• Decision-making capacity — a clinical judgment that a person can understand information, appreciate how it applies to them, reason about options, and communicate a choice. Competence is a legal determination made by a court.
• Surrogate decision-maker — acts for a client who lacks capacity, using substituted judgment (what the client would have wanted) first, and best interests when the client's wishes are unknown

A general ethical decision-making model (steps as usually taught)

1. Identify the problem — is it an ethical dilemma? Whose decision is it?
2. Gather the relevant facts — medical, social, legal, the client's wishes and values
3. Clarify values — of the client, family, nurse, team, institution, and profession
4. Identify options and their likely consequences, with the principles each option supports
5. Decide and act — choose the option best supported by the principles and the client's values
6. Evaluate the outcome and the process

Other frameworks

• Four-box (four-topics) method — medical indications (beneficence, nonmaleficence), patient preferences (autonomy), quality of life, and contextual features (family, cost, law, religion, justice)
• MORAL model — Massage the dilemma, Outline options, Resolve the dilemma (review criteria), Act by applying the chosen option, Look back and evaluate
• Institutional resources — ethics committees and ethics consultation services, palliative care teams, chaplaincy, risk management, and legal counsel

Research ethics landmarks

Informed consent for research requires disclosure of purpose, procedures, risks, benefits, alternatives, confidentiality, voluntariness, and the right to withdraw at any time without penalty.

Major bioethical issues

• Advocate: ensure the client's voice and values are heard; ask whether the client has capacity and whether an advance directive exists
• Clarify, don't decide for the client: nurses facilitate communication among the client, family, and team
• Assess understanding before and after consent discussions; notify the provider if the client does not understand
• Respond to a wish to die: assess for depression, uncontrolled pain, suicidal ideation, and fear; explore the meaning with open-ended questions; report to the team. Do not dismiss or ignore the statement.
• Report unsafe or unethical practice through the chain of command (charge nurse, manager, ethics or compliance office)
• Use ethics consultation when conflicts persist
• Care for self and colleagues experiencing moral distress (debriefing, employee support)

• Surrogate authority comes from an advance directive naming an agent, a court-appointed guardian, or a state default surrogate hierarchy (usually spouse, adult children, parents, adult siblings; order varies by state)
• A surrogate's consent is valid only if the client lacks capacity; verify the surrogate's legal authority before relying on it
• Life-sustaining treatment decisions follow state law and the Patient Self-Determination Act requirements for advance directives (Topic 6)
• MAID is legal only where state law authorizes it and only under that law's procedures
• Research requires IRB approval; participants may withdraw at any time
• Nurses are protected when they report unsafe practice in good faith through proper channels; many states have whistleblower protections, which vary

Case 1. The family of a man with terminal cancer asks the nurse not to tell him his prognosis. Correct action: first gather facts and clarify values — ask the family about their concerns and ask the client how much he wants to know; bring the issue to the provider and team. Why: step 2 of the model precedes action; the client with capacity holds the right to information.

Case 2. A client with end-stage kidney disease and full capacity refuses further dialysis. Correct action: confirm the decision is informed and consistent, explore reasons (depression, burden, pain), ensure the provider discusses consequences, and support the decision with palliative care. Why: a capable adult may refuse life-sustaining treatment.

Case 3. A nurse sees a colleague delay needed pain medication repeatedly. Correct action: address it with the colleague if safe, and report to the charge nurse or manager; ensure the client receives analgesia now. Why: advocacy and nonmaleficence take priority over collegial loyalty.

Case 4. A daughter of a woman with advanced dementia wants to sign surgical consent. Correct action: verify the mother lacks capacity and that the daughter has legal authority (agent under a health care power of attorney, guardian, or default surrogate under state law). Why: surrogate consent is valid only with both conditions.

• Acting before gathering facts — the model starts with identifying the problem and gathering facts
• Treating "withdrawing" as more wrong than "withholding" — they are ethically equivalent
• Confusing MAID (client self-administers; legal in some states) with euthanasia (illegal everywhere in the US)
• Assuming DNR means "do not treat"
• Letting the bedside nurse or treating team make the organ donation request instead of the OPO or designated requester
• Assuming the next of kin automatically decides — capacity and legal authority must be established
• Treating capacity (clinical) and competence (legal) as identical

• Model steps: identify problem → gather facts → clarify values → options → decide and act → evaluate
• Four-box: medical indications, patient preferences, quality of life, contextual features
• Belmont: respect for persons, beneficence, justice; Nuremberg: voluntary consent essential; IRB required for human research
• A capable adult may refuse any treatment, including life-sustaining treatment
• Withholding and withdrawing are ethically equivalent; DNR covers CPR only
• MAID legal in some states; euthanasia illegal in all
• Hospitals must notify the OPO of every death or imminent death
• GINA protects against genetic discrimination in health insurance and employment
• Surrogates use substituted judgment first, then best interests
• Conscientious objection never permits abandonment