1. Lachman, Vicki D. APRN, MBE, PhD


Here's a practical guide to solving difficult ethical dilemmas by considering your professional duties and your own qualities of honesty, compassion, and self-respect.


Article Content

WHAT'S THE RIGHT THING TO DO in situations such as these?

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

* A favorite neighbor of yours is admitted to your unit with a life-threatening condition. When a mutual friend asks about his status, what should you say?


* An older patient admits that she's agreed to have surgery in a few hours because her daughter wants her to have it, not because she wants it. What should you do?



Nurses face ethical dilemmas such as these every day, often with little to guide them. In this article, I'll provide a practical road map to sorting through difficult ethical issues by focusing on two perspectives: your obligations as a professional nurse and the virtues needed to make morally sound decisions, such as honesty, compassion, and self-respect.


Four obligations, six virtues

By addressing the ethical obligations and duties of nurses, the Code of Ethics for Nurses helps you answer the question, "What should I do in this situation?" It identifies four primary obligations you must meet to fulfill the contract between nursing and the public:


* respecting the patient's privacy and protecting confidentiality


* communicating honestly about all aspects of the patient's diagnosis, treatment, and prognosis


* conducting an ethically valid process of informed consent


* advocating for the patient's expressed interests or best interests.1



A related concept, virtue theory, addresses the question, "How should I be?" It deals with moral questions from the model of what a good man or woman would do. Although it doesn't ignore the question, "What should I do?," it focuses on questions of character rather than action.


Virtues are best understood as qualities a person possesses that motivate her to act in a moral or ethical way. The Code defines virtues as character traits that incline people to do the right thing.1 These six virtues apply to nursing:


* professional competence


* honesty and integrity


* caring and compassion


* fairness and justice


* respect and self-respect


* courage.



Provision 5 in the Code speaks directly to importance of character. A nurse owes the same duties to herself as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. For more discussion of these points, see How key virtues apply to nursing.


Meeting your obligations

Now let's look at how your four primary professional obligations to patients are influenced by the six virtues.


1. Protecting privacy and confidentiality. The basic obligation to maintain a patient's privacy and confidentiality has existed since the time of Hippocrates, yet many nurses violate this principle without thinking. For example, suppose a friend asks you about your neighbor who's been admitted to the hospital unit where you work. Even a casual reply about his condition violates his privacy. In fact, so does simply verifying his admission to the hospital.


Respecting the patient means not invading or denying his privacy. If you commented about your patient to your friend, even though you weren't acting out of malevolence, you'd fail to demonstrate the virtue of respect and integrity.


Your patient has a right to expect that you'll hold his diagnosis, prognosis, and personal history in utmost confidence. Share information about his condition only with those involved in his care who need to know.


2. Communicating honestly. Veracity is the ethical principle that obligates you to tell the truth. At times the truth may be painful for the patient or his family to hear, but honesty is a core virtue; only under unusual circumstances is violating it acceptable. To act from the virtues of honesty and compassion requires you to make sure that bad news is delivered in an honest and compassionate way. Here's a six-step model to help you discuss unwelcome news in a competent way.2


* Help the physician get the physical context right. Ask the patient if he'd like to have any family members present when the physician discusses the results of tests or surgery. As much as possible, prevent interruptions to the conversation. Encourage the physician to sit down to deliver news to the patient or his family. Have a box of tissues close by.


* Find out what the patient and family already know. For example, when the physician leaves and the patient begins to ask you questions, you can ask, "What do you understand about your illness?" This is the time to assess the ability of the patient and family to comprehend more bad news.


* Determine how much the patient wants to know (or not know). Ask him, "Did you receive enough information to understand your condition?" Also find out if he wants a family member or other surrogate to communicate on his behalf.


* Communicate the distressing information in a sensitive, straightforward manner. As a nurse, you won't be the first person to break bad news about a diagnosis, a prognosis, or test results. But the patient may ask you to clarify the message he's received. For example, you may need to say, "I'm sorry to have to tell you this. Yes, your physician said the scan did show a tumor in your abdomen."



Then pause and wait for his reaction. Don't try to soften or minimize the severity of the situation because this may confuse him.


* Give the patient and his family time to react and be prepared for an emotional outburst. You could say, "This is difficult news. How can I help you now?"


* Develop a plan for the next steps and follow-up needed. Discuss potential sources of support. Assess the safety of the patient if he's leaving after receiving bad news.



You'll sometimes need the virtue of courage when you tell the truth to a patient or family and in many other circumstances you encounter as a nurse. I've defined moral courage as the capacity to overcome fear and stand up for one's core values.3 It's the willingness to speak out and do what's right in the face of forces that influence you to act in some other way. Besides physical harm, these forces include the threat of humiliation, rejection, ridicule, unemployment, and loss of social standing.4 But nurses who fail to act ethically experience personal losses of self-respect, integrity, and justice.


3. Conducting an ethically valid informed-consent process. What's your responsibility in the process of informed consent? Most nurses believe they're responsible only for witnessing the signature of the patient. But according to the Code, you're responsible for ensuring much more (see Criteria for informed consent).1 For example, you're obligated to assess the patient's ability to make an informed decision about his care. His cognitive abilities may fluctuate because of medication, surgery, unfamiliar surroundings, or his disease. As his nurse, you're in the best position to assess his ability to understand issues related to his care and give valid consent.5


This relationship also helps you determine if his consent is truly voluntary. Imagine that an 82-year-old patient with diabetes confides that she doesn't really want to have an above-knee amputation; she's doing it only to please her daughter, who's unwilling to face her death. She asks you not to tell her daughter and says she feels better just telling someone her true feelings. She's already signed the consent form and is scheduled for surgery in the morning. What should you do?


This situation calls for patient advocacy and probably a family meeting as well. The virtue of caring will likely trigger the nurse's desire to help the patient, but the virtue of courage will be needed to confront this difficult situation. The nurse now experiences an ethical conflict between maintaining confidentiality and supporting a valid informed consent. The nurse is obligated to contact the surgeon because of possible coercion by the patient's daughter. According to the Code, "duties of confidentiality [aren't] absolute and may need to be modified[horizontal ellipsis]to protect the patient."1


The family meeting, orchestrated by patient relations, the ethics committee, or an ethics consultant, could be uncomfortable for all concerned. However, as her nurse you must take responsibility for caring for the patient, respecting the truth, and advocating for the patient. Such a meeting is time-consuming, and the surgeon and the patient's daughter aren't likely to welcome it. But the question is simple: How will you feel if you send the patient to surgery without speaking up, knowing what you know? The treatment decision could change from surgery to a referral for hospice care, which would provide family support for the patient's daughter.


4. Advocating for the patient's best interests. This is what puts action into your obligations. Being passive or active is a choice. Positioning yourself as the patient's advocate in the case we just discussed would be very difficult, especially if you suspect the surgeon will be angry and know that the patient may back down in the face of pressure from her daughter.


I hope that you would choose to act with courage, which involves supporting your professional obligations, standing up to an angry physician, and doing what you think is right for the patient.


Advocacy is often inhibited by the institutional bureaucracy. Nurses must feel free to engage in advocacy roles in health care environments; otherwise, patient self-determination will be truly lost in the morass of rules, regulations, and nurse timidity. Standing up in advocacy requires overcoming the challenges of moral blindness, moral complacency, and moral distress.6 (See A question of morals.)


Ethics in action

To act ethically, you need to know more than your professional obligations outlined in the Code.1 Your actions and decisions as a nurse are manifestations of your true character. Virtue theory provides a framework for key areas of character development. You can learn obligations and strengthen your character. Both require education, perseverance, and often the virtue of courage.


How key virtues apply to nursing

The virtue of professional competence calls for continual professional growth and a commitment to lifelong learning. You must practice nursing that's evidence-based, be knowledgeable about the scope and standards of nursing practice, and have the necessary skills to perform nursing tasks effectively. For example, consider the current evidence and skills required for professionally competent patient transfers. Research shows that best practices include having peer safety leaders on each shift to coach ergonomics and the use of lifts. What does this have to do with ethics? To follow best practices for patient transfer, you must have the courage to demand lifts and the integrity to use them consistently. When nursing actions are in sync with the evidence, your practice environment supports integrity.


Because of cost and access constraints in today's health care environment, the virtues of honesty and integrity are constantly under assault. Integrity can be preserved only if nurses' actions are consistent with the values and ethics of the profession. If honesty and integrity are compromised, we lose self-respect, which further menaces the wholeness of character.


The Code of Ethics for Nurses supports your right to conscientious objection "in situations of compromise that exceed acceptable moral limits or involve violations of the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice."1 Expressing a conscientious objection isn't just stating a personal preference or making an arbitrary choice. It's refusing to participate because you find the requested action morally unacceptable.


Caring and compassion and fairness and justice are also addressed in the Code: "Excellences such as compassion, patience, and skill are habits of character of the morally good nurse."1


Nurses are obligated to create and sustain a nursing practice environment that enables them to fulfill their ethical obligations. This could involve participating on an ethics committee or practice council, acting as a preceptor for new nurses, or working to change unfair polices within or outside the organization.


Your obligation to justice extends beyond the walls of the workplace because nurses have a responsibility to address broader health disparity concerns, such as world hunger, violation of human rights, and inequitable distribution of health care resources.1


Criteria for informed consent


1. Capacity (to understand and decide)


2. Voluntariness (in deciding)


3. Disclosure (of information)


4. Recommendation (of a plan)


5. Understanding (of plan, risks, and recommendation)


6. Decision (in favor of plan)


7. Authorization (of chosen plan)


Source: Fletcher JC, et al., Fletcher's Introduction to Clinical Ethics, University Publishing Group, 2005.


A question of morals

Here are three ways of responding to moral problems. To practice ethically, all must be overcome.


Moral blindness describes seeing a dilemma as an administrative or clinical quandary rather than an ethical issue. For example, the understaffing of the unit doesn't allow for time-consuming comfort care to terminally ill patients, but the problem is considered an administrative staffing problem rather than a moral problem. Or inadequate pain control might be seen as lack of pain management expertise instead of a nurse's lack of awareness of her ethical obligation to manage pain.1


Moral complacency indicates a general satisfaction with one's own opinion of a situation. For example, a nurse might conclude that all terminally ill patients are naturally depressed. This contentment with one's opinion can lead to a lack of action in advocating to treat a patient's depression. A nurse who lacks the virtue of competency doesn't think through the problem critically.


Moral distress can be described as "the conflict between the nurse's knowledge of the ethically appropriate action and the institutional constraints that prevent or make the action difficult."7 This definition speaks to the organization's responsibility for providing an ethical work environment. However, no matter how difficult, the nurse's ethical duty is to advocate for patients. This requires the virtues of integrity, respect, caring, and courage.


Source: Davis, et al., 2006.6




1. American Nurses Association. Code of Ethics for Nurses with Interpretative Statements. American Nurses Publishing, 2001. [Context Link]


2. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Johns Hopkins University Press, 1992. [Context Link]


3. Lachman VD. Moral courage: A virtue in need of development? Medsurg Nursing. 16(2):131-133, April 2007. [Context Link]


4. Kidder RM. Moral Courage. HarperCollins Publishers, 2005. [Context Link]


5. Lachman VD (ed). Applied Ethics in Nursing. Springer Publishing, 2006. [Context Link]


6. Davis AJ, et al. Essentials of Teaching and Learning in Nursing Ethics: Perspectives and Methods. Churchill Livingstone, 2006. [Context Link]


7. Corley MC, et al. Nurse moral distress and ethical work environment. Nursing Ethics. 12(4):381-390, July 2005. ****RESOURCE [Context Link]



Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press, 2002.