Ethical Issues

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Ethical Issues

Linda D. Urden

It is essential that critical care nurses have an understanding of professional nursing ethics and ethical principles and that they are able to use a decision-making model to guide nursing actions. This chapter provides an overview of ethical principles and professional nursing ethics. An ethical decision-making model is described and illustrated, and recommendations are given concerning methods to use when confronting ethical issues in the critical care setting.

Differences between Morals and Ethics

Morals are the “shoulds,” “should nots,” “oughts,” and “ought nots” of actions and behaviors, and they are related closely to cultural and religious values and beliefs that govern our social interactions. Morals form the basis for action and provide a framework for the evaluation of behavior.1

Ethics are concerned with the basis of the action rather than whether the action is right or wrong, good or bad. Imposition of ethics implies that an evaluation is being made that is based on or derived from a set of standards. It refers to what rules are required to prevent harm to persons and to the collective beliefs and values of a community or profession.1

Moral Distress

Recently, moral distress has been a topic widely discussed in the literature as a serious problem for nurses.25 Nurses face multiple challenges on a daily basis: emergency situations, tension from conflict with others, complex clinical cases, new technologies, increasing regulatory requirements, acquisition of new skills/knowledge, staffing issues, financial constraints, workplace violence, to name a few. This care environment has led to increasingly complex moral and ethical dilemmas.5 In addition, they frequently may experience emotional outbursts from patients, families, co-workers, and feel a lack of control and “burnt out.”2,5 Moral distress occurs when a person knows the ethically appropriate action to take but cannot act on it. It also manifests when a nurse acts in a manner contrary to personal and professional values. As a result, there can be significant emotional and physical stress that leads to feelings of loss of personal integrity and dissatisfaction with the work environment. Relationships with co-workers and patients are affected, and the quality of care can be negatively affected. There is also a great impact on personal relationships and family life; nurses experiencing moral distress may resign their position or leave the profession entirely.3

It is therefore important that nurses recognize moral distress and actively seek strategies to address the issue through institutional, personal, and professional organizational resources. Knowledge and application of ethical principles and guidelines can assist the nurse in daily practice when ethical dilemmas occur. Box 2-1 provides a position statement on moral distress, promulgated by the American Association of Critical-Care Nurses (AACN).6 The document is evidence-based, providing additional references for the reader. There is also a reference to ensuring that support to alleviate moral distress is present in a healthy work environment (see Chapter 1). Actions are listed for direct care staff nurses as well as employers.

Box 2-1

Aacn Position Statement

Moral Distress


Compelling evidence indicates that moral distress has a negative impact on the healthcare work environment. In one study, 1 in 3 nurses experienced moral distress.1 In another, nearly half the nurses studied left their units or nursing altogether because of moral distress.2

Additional studies have shown:

AACN Calls to Action

For Nurses

Every nurse must:

• Recognize and name the experience of moral distress (moral sensitivity).

• Affirm the professional obligation to act and commit to addressing moral distress.

• Be knowledgeable about and use professional and institutional resources to address moral distress, such as:

• Actively participate in professional activities to expand knowledge and understanding of the impact of moral distress.

• Develop skill, through the use of mentoring and resources, to decrease moral distress.

• Implement strategies to accomplish desired changes in the work environment while preserving personal integrity and authenticity.

For Employers

Every organization must:

• Implement interdisciplinary strategies to recognize and name the experience of moral distress.

• Establish mechanisms to monitor the clinical and organizational climate to identify recurring situations that result in moral distress.

• Develop a systematic process for reviewing and analyzing the system issues enabling situations that cause moral distress to occur and for taking corrective action.

• Create support systems that include:

• Create interdisciplinary forums to discuss patient goals of care and divergent opinions in an open, respectful environment.

• Develop policies that support unobstructed access to resources such as the ethics committees.

• Ensure nurses’ representation on institutional ethics committees with full participation in all decision making.

• Provide education and tools to manage and decrease moral distress in the work environment.


1. Redman, B, Fry, ST. Nurses’ ethical conflicts: what is really known about them? Nurs Ethics. 2000; 7(4):360.

2. Millette, BE. Using Gilligan’s framework to analyze nurses’ stories of moral choices. West J Nurs Res. 1994; 16(6):660.

3. Solomon, M, O’Donnell, L, Jennings, B, et al. Decisions near the end of life: professional views on life sustaining treatments. Am J Public Health. 1993; 83:14.

4. Kelly, B. Preserving moral integrity: a follow-up study with new graduate nurses. J Adv Nurs. 1998; 28:1134.

5. Wilkinson, JM. Moral distress in nursing practice: experience and effect. Nurs Forum. 1987-1988; 23(1):16.

6. Perkin, RM, Young, T, Freier, MC, et al. Stress and distress in pediatric nurses: lessons from Baby K. Am J Crit Care. 1997; 6:225.

7. Fenton, M. Moral distress in clinical practice: implications for the nurse administrator. Can J Nurs Adm. 1988; 1:8.

8. Davies, B, Clarke, D, Connaughty, S, et al. Caring for dying children: nurses’ experiences. Pediatr Nurs. 1996; 22:500.

9. Krishnasamy, M. Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer. Cancer Nurs. 1999; 22:251.

10. Anderson, SL. Patient advocacy and whistle-blowing in nursing: help for the helpers. Nurs Forum. 1990; 25:513.

11. Hefferman, P, Heilig, S. Giving “moral distress” a voice: ethical concerns among neonatal intensive care unit personnel. Cambridge Q Healthc Ethics. 1999; 8:173.

12. Corley, MC. Moral distress of critical care nurses. Am J Crit Care. 1995; 4:280.


Corley, MC, Elswick, RK, Gorman, M, et al. Development and evaluation of a moral distress scale. J Adv Nurs. 2001; 33(2):250.

Corley, MC, Minick, P. Moral distress or moral comfort. Bioethics Forum. 2002; 18(1-2):7.

Cronqvist, A, Theorell, T, Burns, T, et al. Caring about–caring for: moral obligations and work responsibilities in intensive care nursing. Nurs Ethics. 2004; 11(1):63.

Erlen, JA, Sereika, SM. Critical care nurses, ethical decision making and stress. J Adv Nurs. 1997; 26:953.

Jameton, A. Dilemmas of moral distress: moral responsibility and nursing practice. Clin Issues Perinat Womens Health Nurs. 1993; 4:542.

Jameton, A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.

Kalvemark, S, Hoglund, AT, Hansson, MG, et al. Living with conflicts: ethical dilemmas and moral distress in the health care system. Soc Sci Med. 2004; 58(6):1075.

Liaschenko, J. Artificial personhood: nursing ethics in a medical world. Nurs Ethics. 1995; 2:185.

Penticuff, JH, Waldren, M. Influence of practice environment and nurse characteristics on perinatal nurses’ responses to ethical dilemmas. Nurs Res. 2000; 49(2):64.

Raines, ML. Ethical decision making in nurses: relationships among moral reasoning, coping style, and ethics stress. JONAS Healthc Law Ethics Regul. 2000; 2(1):29.

Rushton, CH. The Baby K case: ethical challenges of preserving professional integrity. Pediatr Nurs. 1995; 21:367.

Storch, JL, Rodney, P, Pauly, B, et al. Listening to nurses’ moral voices: building a quality health care environment. Can J Nurs Leadersh. 2002; 15(4):7.

Sundin-Huard, D, Fahy, K. Moral distress, advocacy and burnout: theorizing the relationships. Int J Nurs Pract. 1999; 5(1):8.

U.S. General Accounting Office. Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors [Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives]. Washington, DC: US General Accounting Office.

From American Association of Critical-Care Nurses. Position Statement: Moral Distress. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2008.

The AACN has created a framework—The 4A’s to Rise Above Moral Distress—to support nurses who are experiencing moral distress (Figure 2-1). ASK, the first stage, is a self-awareness and reflection period in which one becomes more aware of the distress and its effects on oneself. Specific areas to address are physical, spiritual, emotional, and behavioral responses. During stage two, AFFIRM, one affirms the distress and makes a commitment to take care of oneself. In stage three, ASSESS, one needs to identify the timing and context of when the stressors occur; determine the severity of the distress; and examine one’s readiness to act. The final stage, ACT, consists of preparation, the action itself, and maintaining the desired change. Although the model was created by AACN, it is a framework that can be used in diverse settings and by various health care professionals.7 McCue8 reported using this model as a resource for resolving an issue between a chief nurse executive and chief executive officer. In this case, the impact of the outcome was at the organizational level.

Ethical Principles

Certain ethical principles were derived from classic ethical theories that are used in health care decision making. Principles are general guidelines that govern conduct, provide a basis for reasoning, and direct actions. The six ethical principles that are discussed in this chapter are autonomy, beneficence, non-maleficence, veracity, fidelity, and justice (Box 2-2).


The concept of autonomy appears in all ancient writings and early Greek philosophy. In health care, autonomy can be defined as an agreement to respect another’s right to self-determine a course of action and the support of independent decision making11 without coercion or interference from others. Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events.

The critical care nurse is often “caught in the middle” in ethical situations, and promoting autonomous decision making is one of those situations. As the nurse works closely with patients and families to promote autonomous decision making, another crucial element becomes clear. Patients and families must have all of the information about a particular situation before they can make a decision that is best for them. They should be given all the pertinent information and facts, and they must have a clear understanding of what was presented. This is where the nurse is a most important member of the health care team—as patient advocate, the nurse provides more information as needed, clarifies points, reinforces information, and provides support during the decision-making process. Box 2-3 presents the Nursing Interventions Classification (NIC) feature on nursing intervention activities that facilitate decision making.


The concept of doing good and preventing harm to patients is the sine qua non for the nursing profession. However, the ethical principle of beneficence—which requires a nurse to promote the well-being of patients—points to the importance of this duty for the health care professional. The principle of beneficence presupposes compassion; taking positive action to help others; desire to do good. It is the core principle of patient advocacy.11 Harms and benefits are balanced, leading to positive or beneficial outcomes. In approaching issues related to beneficence, conflict with another principle, that of autonomy, is common. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient.

Traditional health care has been based on a paternalistic approach to patients. Many patients are still more comfortable in deferring all decisions about care and treatment to their health care provider. Active involvement by various organizations, agencies, and consumer groups in regard to health care has demonstrated a trend toward the public’s need and desire for more information about health care in general and more information about alternative treatments and providers. Paternalism may always be a possibility in the health care setting, but enlightened consumers are causing a change in this practice.

In the critical care setting, many instances of and possibilities for paternalistic actions by the nurse exist. Postoperative care, which is designed to assist the patient with achieving a quick recovery, is a good example. Encouraging the patient to turn, cough, and deep breathe and increasing the patient’s activity in the form of dangling, sitting in a chair, and ambulating are all paternalistic actions when the patient is experiencing pain and sleep deprivation and wanting to be left alone. However, the benefits and harms sometimes must be balanced. In these instances, the duty to do no harm—which is the next principle to be discussed—takes precedence over the need to avoid paternalistic actions. When ethical principles are in conflict, the nurse must weigh all the benefits and choose the best principle to follow.


Another ethical principle that is closely related to autonomy and veracity is fidelity. Fidelity, or faithfulness and promise-keeping to patients, is an essential aspect of nursing. The American Nurses Association (ANA) states that this principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based on the virtue of caring.11 It forms a bond between individuals and is the basis of all professional and personal relationships. Regardless of the amount of autonomy that patients have in critical care areas, they still depend on the nurse for many types of physical care and emotional support. A trusting relationship that establishes and maintains an open atmosphere is one that is positive for all involved.

Like all of the other principles, fidelity extends to the family of the critical care patient. When a promise is made to family members that they will be called if an emergency arises or that they will be informed of any other special events concerning the patient, the nurse must make every effort to follow through on the promise. Fidelity upholds the nurse-family relationship and reflects positively on the nursing profession as a whole and on the institution in which the nurse is employed.

Confidentiality is one element of fidelity that is based on traditional health care professional ethics. Confidentiality is described as a right whereby patient information may be shared only with those involved in the care of the patient. An exception to this guideline might occur if the welfare of others would be put at risk by keeping patient information confidential. In this situation, the nurse must balance ethical principles and weigh risks and benefits. Special circumstances, such as the existence of mandatory reporting laws, guide the nurse in certain situations.