Neonatal ethics, Nursing ethics, Perinatal ethics.



  1. Callister, Lynn Clark PhD, RN, FAAN
  2. Sudia-Robinson, Tanya PhD, RN


Ethical issues across the childbearing year are multiple and complex. This article addresses ethical challenges facing maternal-child nurses and identifies strategies for making ethical decisions utilizing ethical principles and frameworks. Coping strategies for dealing with moral distress, how nurses demonstrate moral courage, and the attributes of an effective ethical decision maker are described. Ethical issues related to healthcare team relationships are discussed, with implications for nurses provided.


Article Content

Ethical issues occur throughout the childbearing year and are therefore confronted commonly by perinatal and neonatal nurses. There are over 4 million births occurring in the United States yearly, and childbirth is the most common reason for hospitalization (Childbirth Connection, 2010). This article addresses ethical challenges facing maternal-child nurses and identifies strategies for making clinical decisions utilizing ethical principles and frameworks.

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

Ethical Principles and Frameworks

Ethical principles that guide ethical action include four primary moral principles: respect for beneficence, nonmaleficence, justice, and autonomy, which upholds the rights of individuals and families (Thompson, 2008). A key way for nurses to respect autonomy is through support of childbearing women, including adolescent women (emancipated minors) (Association of Women's Health, Obstetric, and Neonatal Nurse [AWHONN], 2009a) in exercising control over their reproductive health and in making decisions on behalf of their children.


Beneficence is the obligation to do good, as compared to nonmaleficence, which is the obligation to do no harm. These two principles should be considered in relationship to healthcare technology that has the ability to sustain life without accurate predictions of long-term outcomes. Justice is the principle of treating everyone fairly through providing comparative and equitable treatment.


Other principles important in interactions with women and children and their families as well as healthcare professionals include fidelity, veracity, confidentiality, and privacy (Beauchamp & Childress, 2008). Fidelity is the obligation to keep commitments. Veracity is the obligation to demonstrate integrity and truth-telling, disclosing to women and their families accurate information regarding the relative risks and benefits of health management. Privacy and confidentiality of patient information are clearly outlined in the American Nurses Association (ANA) Code of Ethics for Nurses (2001).


The importance of basing clinical practice on ethical principles has been clearly identified: "Nursing ethics view as relevant the entirety of human experiences...Nursing ethics have evolved from nursing's rich history of collective narratives-stories of compassion, duty, giving, touching, and close contacts with an infinite array of human struggles and transcendence" (Penticuff, 2008, p. 289).


Frameworks for ethical practice include virtue ethics, which focuses on character and morality rather than obligations and rights. Deontology or duty ethics (Kantanism) focuses on the professional responsibilities with an emphasis on rules and principles. The framework of utilitarianism focuses on doing the greatest good for the greatest number of people. The framework of justice is another framework that focuses on distributing resources equally. The ethics of caring emphasizes empathy and concern and the responsibility nurses have to demonstrate compassion and empathy. Feminist ethics focuses on understanding the sociocultural context of the lives of women in making ethical decisions (Liaschenko & Peter, 2006).


How Do Nurses Participate in Ethical Decision Making?

An ethical dilemma is a situation that often has no clear "right" or "wrong" resolution and is fraught with the potential to violate ethical principles and standards of professional practice. Models of ethical decision making are similar to the nursing process, which includes assessment, diagnosis, outcomes/planning, implementation, and evaluation.


First, assess what the ethical dilemma is, including health concerns and decisions or actions that need immediate response. This requires moral sensitivity (monitoring for ethical situations) and moral character (acting in an ethical and professional manner). Second, gathering data is essential, including identifying the stakeholders, their decisional capacity, and what sociocultural considerations are important. Recognizing and addressing any potential human rights violations is also essential. Additionally, examine whether there any legal issues or institutional policies that should be considered. This requires moral motivation or making moral judgment. Step three is exploring potential options. Is the situation a true dilemma between "good and bad," or between two "goods" or between the lesser of two "bads?" It is a trilemma? Can a third option that represents a compromise be identified? Who should make the needed decisions? What are the anticipated outcomes of each action that could be taken? For example, asking what option would result in the most good is a utilitarian approach. Asking what option respects the rights of all parties is a rights approach. A justice approach treats all options equally. Asking what option best serves the community is a common good approach. A virtue approach means asking what option is congruent with one's personal values (Markkula Center for Applied Ethics, 2009).


Step four focuses on implementation of the most acceptable option and step five, evaluating the outcomes and determining whether any additional actions are indicated. Reflecting on what was learned from the experience is also helpful (Burkhardt & Nathaniel, 2008; Butts & Rich, 2008; Judson, Harrison, & Hicks, 2010; Narrigan, 2004; Rest, 1979).


It is essential that ethical decision making is framed by professional codes of ethics, including the ANA (ANA, 2001) Code of Ethics for Nurses with Interpretive Statements and the International Council of Nurses (2006)Code of Ethics for Nurses (Table 1). The nine provisions with interpretive statements of the American Nurses Association Code of Ethics (2001), including the primacy of advocacy for the patient and the demonstration of respect and compassion are available to view online. The ANA Code is "an expression of professionalism" (Dahnke, 2009, p. 113), including values and commitments, duties to patients, and obligations to society. The ANA code describes the legacy of ethical practice in nursing as "self reflective, enduring, and distinctive" (ANA, p. 5). The ANA code suggests that nurses' ethical judgments should be responsive to social values and community needs. The ICN code provides an important global perspective to ethical nursing practice. The AWHONN Standards for Professional Nursing Practice in the Care of Women and Newborns includes an ethics standard (Table 2), which states that "The registered nurses decisions and actions on behalf of women, fetuses, and newborns are determined in an ethical manner and guided by a sound framework for an ethical decision-making process" (AWHONN 2009c, p. 9). In addition, the responsibilities and rights of perinatal nurses are outlined in an AWHONN position statement (AWHONN, 2009b).

Table 1 - Click to enlarge in new windowTable 1 The International Council of Nursing Code of Ethics for Nurses

"The ethics of daily clinical practice may not be dramatic and are often less visible than ethical dilemmas publicized in the media." These daily ethical challenges are so important for nurses practicing using the ethics of caring (Ulrich et al., 2010). In a recent issue of MCN, The American Journal of Maternal/Child Nursing, the editor states, "nothing is more crucial than being true to yourself and having integrity" (Freda, 2010, p. 251). Meeting these challenges can make a tremendous difference in professional satisfaction for nurses and enhance the quality of care for women and newborns. "Little things mean a lot!!"

Table 2 - Click to enlarge in new windowTable 2. Association of Women's Health, Obstetric, and Neonatal Nurses Ethics Standard

Moral Distress and Moral Courage

Moral distress often occurs when a nurse has the sense that she or he has not done what a "good nurse" would have done in a clinical situation fraught with ethical dilemmas, or when the nurse feels powerless to act according to his or her ethical and moral values (Epstein & Delgado, 2010; Ulrich, Hamric, & Grady, 2010; Fry, Veatch, & Taylor, 2011). According to Schulter, Winch, Holzhauser, and Henderson (2008, p. 314), "When nurses feel ignored when trying to act in the best interests of patients, they frequently experience feelings of powerlessness and moral distress." Rashotte (2004) refers to moral distress as "dwelling with stories that haunt us" (p. 34).


The challenge may be not determining what action is ethical, but constraints that may impede nursing action. Internal constraints may include fear of losing a position, ineffectiveness experienced in the past, and lack of self-confidence, and lack of courage. External constraints may include other members of the healthcare team, legal issues, institutional "culture" and socialization by peers, and nursing/hospital administration, and policies/procedures (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005; Jensen & Lidell, 2009; Zuzelo, 2007). Moral distress in neonatal nurses may occur when there are disagreements between the wishes of the family and the recommendations of providers in critically ill newborns (Janvier, Nadeau, Deschenes, Courte, & Barrington, 2007; Lantos, 2007).


The American Association of Critical Care Nurses (2004) generated a model to guide nurses in managing moral distress: ASK what you are feeling, AFFIRM your distress and commit to address moral distress, ASSESS the sources of distress, and ACT according to your personal and professional values. The more experience nurses have acting according to their values (i.e., demonstrating moral courage), the more likely it is that nurses will demonstrate moral certainty (Wurzbach, 2008).


Implications for Moral Distress and Moral Courage for Nursing Clinical Practice:


1. Coping strategies for dealing with moral distress include improving communication with patients and families, with the interdisciplinary healthcare team and between nursing and management; and developing a safe place for ethical discussions (Murray, 2010)


2. Nurses can offer the strongest support for each other (LaSala & Bjarnason, 2010), and nurse ethicists are often helpful. According to Schroeter (2007, p. 64), "the clinical ethicist can support nurses as a peer in making effective clinical decisions by listening, providing guidance, and being sensitive to one's own value systems as well as those of colleagues"


3. Institutional ethics committees are another important resource for nurses and can be utilized in a proactive manner to prevent interprofessional conflict


4. Moral courage has been operationalized using the acronym CODE, which represents C = courage, O = obligation to ethical codes, D = danger management, and E = expression and action (Lachman, 2010).


The attributes of an effective ethical decision maker include moral integrity; sensitivity, compassion, and caring; having a sense of responsibility and empowerment; demonstrating patience and a willingness to deliberate (Burkhardt & Nathaniale, 2008; Jensen & Lidell, 2009; Weaver, 2007). Nurses are referred to as "boundary workers" because they are required to negotiate their obligations to patients, families, members of the healthcare delivery team, and the institution in which they work (Liaschenko & Peter, 2006). As boundary workers, nurse act with moral sensitivity integrity when making ethical decisions. Such nurses demonstrate empathy and awareness of how one's actions affect others. Being attune to one's intuition and acting on that clinical intuition is essential. Moral sensitivity is consistent with the ethics of care.


Healthcare Team Relationships

Respect for others is another important ethical principle related to professional behavior/engagement in healthcare team relationships. It is essential that nurses providing care to women and newborns demonstrate appropriate professional behavior. The myriad of cultural differences that exist in perinatal care settings, including community-based clinics, birthing units, mother/baby units, and the well-baby and NICU nurseries may impact communication between members of the healthcare team. Language barriers, customs, and rituals have the potential to cause tension and miscommunication among women and their healthcare providers. In addition, clinical disagreements may occur between members of multidisciplinary perinatal and neonatal healthcare teams when ethical professional standards are not followed. In 2009, the Joint Commission issued standards to deal with disruptive behaviors defined as conduct interfering with quality and safe care of childbearing families (Mahlmeister, 2009; Veltman, 2007). Any such occurrences should be addressed as soon as possible based on an established code of conduct (Simpson, 2007).


Implications for Healthcare Team Relationships for Nursing Clinical Practice


1. It is essential that nurses mentor and support each other, not engaging in backbiting and gossiping, and role model professional behavior. Horizontal hostility has "no place in the practice of professional nursing" (Simpson, 2008, p. 328)


2. Communication, collaboration, and demonstration of valuing others are essential in order to provide ethical nursing care. One nurse suggested, "Basic courtesy is to really listen, using the same language (with the same meaning) and create TEAM instead of US versus THEM. There needs to be understanding and appreciation of all roles" (Simpson & Lyndon, 2009, p. 36)


3. Standardize protocols based on clinical evidence and conduct ongoing practice drills


4. Speak up when questionable provider practices are occurring. This requires "strong communication skills, assertiveness, and knowledge about conflict resolution and chain of command processes" (Mahlmeister, 2007, p. 286). One nurse described action she would take when she had concerns about fetal distress, "If there are no signs of improvement in the fetal tracing and the physician continues to refuse to come in, I would notify him that I felt it was in the best interest of the patient to have a direct evaluation by a physician and if he is not coming in now, I would call his backup" (Simpson & Lyndon, 2009, p. 33)


5. Follow the chain of command to address clinical concerns. An example of ethical nursing action and appropriate documentation is, "Dr.__ordered oxytocin. Physician was informed at nurses' station at 1205 that patient was contracting every 2 minutes x 50 to 70 seconds and was moderate to palpation. Order to administer oxytocin was questioned. Charge nurse__was informed of communication with physician. The charge nurse spoke with physician who insisted on oxytocin administration. Chief of OB was called by charge nurse at 2010" (Murray & Huelsman, 2009, p. 6)


Ethical dilemmas for maternal-child nurses are complex and merit careful consideration. Nurses can overcome the moral distress associated with such challenges through demonstrating moral courage and advocacy for women and children. A woman-centered, child-centered, and family-centered approach facilitates collaborative decision making and demonstrates respect and valuing. Utilizing ethical principles and standards in care delivery is essential.



American Nurses Association (ANA). Code of ethics for nurses with interpretive statements.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available. (Following path: professional nursing practice > ethics and standards > Center for Ethics and Human Rights)


Creighton Center for Health Policy and Ethics


The Hastings Center


International Center for Nursing Ethics


International Council of Nurses. (2006). Code of ethics for nurses.


National Human Genome Research


Kennedy Institute National Reference Center for Bioethics Literature




American Association of Critical Care Nurses. (2004). Moral distress. Aliso Viejo, CA: Author. [Context Link]


American Nurses Association. (2001). Code of ethics for nurses. Silver Spring, MD: Author. [Context Link]


American Nurses Association. (2001). Code of Ethics with Interpretive Statements. Retrieved from[Context Link]


Association of Women's Health, Obstetric, and Neonatal Nurses. (2009a). Confidentiality in adolescent health care. Position paper. Retrieved from[Context Link]


Association of Women's Health, Obstetric, and Neonatal Nurses. (2009b). Ethical decision making in the clinical setting: Nurses' rights and responsibilities. Retrieved from[Context Link]


Association of Women's Health, Obstetric, and Neonatal Nurses. (2009c). Standards for professional nursing practice in the care of women and newborns (7th ed). Washington, DC: Author. [Context Link]


Austin, W., Lemermeyer, G., Goldberg, L., Bergum, V., & Johnson, M. S. (2005). Moral distress in healthcare practice: The situation of nurses. Health Ethics Care Forum, 17(1), 33-48. [Context Link]


Beauchamp, T. L., & Childress, J. F. (2008). Principles of biomedicalethics (6th ed). New York: Oxford University Press. [Context Link]


Burkhardt, M. A., & Nathaniel, A. K. (2008). Ethics and issues in contemporary nursing (3rd ed). Clifton Park, NY: Thomson Delmar. [Context Link]


Butts, J. B., & Rich, K. L. (2008). Nursing ethics (2nd ed). Boston: Jones & Bartlett. [Context Link]


Childbirth Connection. (2010). United States maternity care facts and figures. April 2010. Retrieved from[Context Link]


Dahnke, M. D. (2009). The role of the American Nurses Association Code in ethical decision making. Holistic Nursing Practice, 23(2), 112-119. [Context Link]


Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. Online Journal of Issues in Nursing, 15(3), Mauscript 1. doi:10.3912/OJIN.Vol15No03Man01 [Context Link]


Freda, M. (2010). Integrity. MCN: The American Journal of Maternal Child Nursing, 35(5), 251. [Context Link]


Fry, S. T., Veatch, R. M., & Taylor, C. (2011). Case studies in nursing ethics (3rd ed). Sudbury, MA: Jones & Bartlett. [Context Link]


International Council of Nurses. (2006). Code of ethics for nurses. Geneva, Switzerland: Author. [Context Link]


Janvier, A., Nadeau, S., Deschenes, M., Couture, E., & Barrington, B. J. (2007). Moral distress in the neonatal intensive care unit: Caregiver's experiences. Journal of Perinatology, 27(4), 203-208. [Context Link]


Jensen, A., & Lidell, E. (2009). The influence of conscience in nursing. Nursing Ethics, 16(1), 31-42. [Context Link]


Judson, K., Harrison, C., & Hicks, S. (2010). Law and ethics for medical careers (5th ed). New York: McGraw-Hill. [Context Link]


Lachman, D. (2010). Strategies necessary for moral courage. Online Journal of Issues in Nursing, 15(3), Manuscript 3. doi:10.3912/OJIN.Vl15No03Man03 [Context Link]


Lantos, J. D. (2007). Moral distress and ethical confrontation: Problem or progress? Journal of Perinatology, 27(4), 201-202. [Context Link]


LaSala, C. A., & Bjarnason, D. (2010). Creating workplace environments that support moral courage. Online Journal of Issues in Nursing, 15(3), Manuscript 4. doi:10.3912/OJIN.Vol15No03Man04 [Context Link]


Liaschenko, J., & Peter, E. (2006). Feminist ethics: A way of doing ethics. In A. Davis, V. Tschudin, & L. de Raeve (Eds.). Essentials of teaching and learning in nursing ethics (pp. 181-190). Philadelphia, PA: Churchill Livingstone-Elsevier. [Context Link]


Mahlmeister, L. R. (2007). "Speaking up:" A positive approach to improving outcomes when obstetrical emergencies arise. Journal of Perinatal and Neonatal Nursing, 21(3), 186-188. [Context Link]


Mahlmeister, L. R. (2009). Promoting positive team interactions and behaviors. Journal of Perinatal and Neonatal Nursing, 23(1), 8-11.


Markkula Center for Applied Ethics. (2009). Making an ethical decision. Retrieved from [Context Link]


Murray, J. S. (2010). Moral courage in healthcare: Acting ethically even in the presence of risk. Online Journal of Issues in Nursing, 15(3), Manuscript 2. doi:10.3912/OJIN.Vol15No3Man02. [Context Link]


Murray, M. L., & Huelsman, C. M. (2009). Labor and delivery nursing: A guide to evidence based practice. New York: Springer. [Context Link]


Narrigan, D. (2004). Examining an ethical dilemma: A case study in clinical practice. Journal of Midwifery and Women's Health, 49(3), 243-249. [Context Link]


Penticuff, J. H. (2008). Suffering, compassion, and ethics: Reflections on neonatal nursing. In W. J. E. Pinch & A. M. Haddad (Eds.). Nursing and health care ethics: A legacy and a vision (pp. 283-292). Silver Spring, MD: American Nurses Association. [Context Link]


Rashotte, J. (2004). Dwelling with stories that haunt us: Building a meaningful nursing practice. Nursing Inquiry, 12(1), 34-42. [Context Link]


Rest, J. R. (1979). Development in judging moral issues. Minneapolis: University of Minnesota Press. [Context Link]


Schroeter, K. (2007). The nurse ethicist: An emerging role in advanced practice. Birth, 34(1), 49-52. [Context Link]


Schulter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses' moral sensitivity and hospital ethical climate. Nursing Ethics, 15(3), 304-321. [Context Link]


Simpson, K. R. (2007). Disruptive clinician behavior. MCN: The American Journal of Maternal Child Nursing, 32(1), 64. [Context Link]


Simpson, K. R. (2008). Horizontal hostility. MCN: The American Journal of Maternal Child Nursing, 33(5), 328. [Context Link]


Simpson, K. R., & Lyndon, A. (2009). Clinical disagreements during labor and birth: How does real life compare to best practice? MCN: The American Journal of Maternal Child Nursing, 34(1), 31-39. [Context Link]


Thompson, J. E. B. (2008). Advocacy for the voices of women, nurses, and midwives. In W. J. E. Pinch & A. M. Haddah (Eds.). Nursing and health care ethics: A legacy and a vision (pp. 105-116). Silver Spring, MD: American Nurses Association. [Context Link]


Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: A growing problem in the health professions. Hastings Center Report, 40(1), 20-22. [Context Link]


Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: Ethical issues and stress in nursing. Journal of Advanced Nursing, 66(11), 2510-2519. [Context Link]


Veltman, L. (2007). Disruptive behavior in obstetrics: A hidden threat to patient safety. American Journal of Obstetrics and Gynecology, 196(6), 587.e1-587.e5. [Context Link]


Weaver, K. (2007). Ethical sensitivity: State of knowledge and needs for further research. Nursing Ethics, 14(2), 141-155. [Context Link]


Wurzbach, M. E. (2008). Moral conviction, moral regret, and moral comfort: Theoretical perspectives. In W. J. E. Pinch & A. M. Haddad (Eds.). Nursing and health care ethics: A legacy and a vision (pp. 57-70). Silver Spring, MD: American Nurses Association. [Context Link]


Zuzelo, P. R. (2007). Exploring the moral distress of registered nurses. Nursing Ethics, 14(3), 344-359. [Context Link]