1. Section Editor(s): Davis, Charlotte BSN, RN, CCRN

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Throughout our nursing careers, we'll encounter ethical dilemmas in many challenging patient care situations. This can cause a great amount of stress as we struggle to identify what's the correct action for each unique situation. Utilizing the ethical principles of autonomy, beneficence, nonmaleficence, fidelity, justice, and paternalism as outlined by the American Nurses Association (ANA) provides us with a firm foundation for ethical decision making.

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Autonomy allows healthcare teams to respect and support a patient's decision to accept or refuse life-sustaining treatments. As patient advocates, it's our duty to ensure that our patients receive all of the necessary information, such as potential risks, benefits, and complications, to make well-informed decisions. The healthcare team can then formulate care in compliance with the patient's wishes. Family members should refrain from making decisions for the patient or inflicting undue pressure to alter his or her decisions unless the patient is incapacitated or found to be legally incompetent. Many factors may influence a patient's acceptance or refusal of medical treatment, such as culture, age, general health, social support system, and previous exposure to individuals who received a similar treatment modality with negative clinical outcomes.


We use nonmaleficence by selecting interventions that will cause the least amount of harm to achieve a beneficial outcome. For example, if a patient verbalizes homicidal ideations with a plan, we may be torn between wanting to ensure patient privacy and our duty to escalate the patient's care to safeguard the public. The principle of nonmaleficence points us to place the safety of the patient and community first in all care delivery.


Beneficence is defined by the ANA as "actions guided by compassion." We utilize beneficence daily as we administer pain medication or hold the hand of a grieving family member.


The ethical principle of fidelity directs us to model care delivery with altruism, loyalty, caring, and honesty. For example, when an older patient with intact cognitive function is diagnosed with a terminal illness and he or she doesn't want to share that information with immediate family, it can create an ethical dilemma. To maintain the trust established in the nurse-patient relationship, don't share any healthcare information without the patient's consent. Consult with other interdisciplinary team members, such as case managers, social workers, and clergy, to help identify supportive services that the patient may need as his or her disease progresses.


Justice leads us to ensure that care is provided on a fair and equal basis, regardless of patients' social or financial status. When we heavily advertise that our organization is providing free flu vaccine clinics to all of the local senior centers, we're using the ethical principle of justice.


Paternalism provides the power for healthcare professionals to make decisions to reveal or conceal a diagnosis, potential treatment modalities, or expected prognosis. An example of paternalism is when we admit an adolescent with multiple complete cervical spine fractures whose family is stating that the teen needs to participate in a state basketball championship in 3 months. The benefit of sharing the anticipated prognosis of quadriplegia at this time is far outweighed by the potential emotional trauma it may cause the family. We then schedule a family-interdisciplinary team meeting in a controlled environment to give them the prognosis.


As nurses, we may even face ethical dilemmas within our peer group if we witness a colleague exhibiting unsafe practices. When we see an immediate patient safety risk, we must act quickly and seek the guidance of our administrative teams and the collaborative expertise of our interdisciplinary team members. We may also need to notify our security teams and/or local police departments.


Nurses have been patient safety advocates for 165 years since Florence Nightingale assumed her first administrative position in 1853. We're known as the most trusted profession because of our dedication to providing patient-centered care in a holistic environment. As we tackle the ethical dilemmas of tomorrow, I encourage you to utilize the ANA's six principles as a compass to guide your decision making.

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