Ethical Principles of Nursing

ANA’s Code of Ethics consists of 9 provisions to serve the following purposes: provide a succinct statement of the ethical values, obligations, and duties of every individual who enters the nursing profession; serves as the profession’s nonnegotiable ethical standard, and expresses nurses’ own understanding of our commitment to society:

1. Respect for the Individual
2. Commitment to the Patient
3. Advocacy for the Patient
4. Responsibility and Accountability for Practice
5. Duties to Self, Others
6. Contributions to Healthcare Environments
7. Advance of the Nursing Profession
8. Collaboration to Meet Health Needs
9. Promotion of the Nursing Profession

Types of Ethical Decisions

Principle Ethics

• Based on obligations
• Focus on finding socially and historically acceptable answers to questions

Virtue Ethics

• Focus on the “character traits of the counselor and nonobligatory ideals to which professionals aspire”
• Am I doing what is in the best interest of my client?

-Corey et al., 2016, p. 10

Other Prominent Approaches:

Utilitarianism (teleology or situational ethics)

• Focuses on the consequences of actions; the end justifies the means.
• Risk or cost-benefit analysis for making ethical decisions.
• Actions that reflect the greatest good for the largest number of people.

Deontology

• To evaluate the actions as being intrinsically right or wrong
• Ethical decisions should be based on duty/obligation to others, principles that are fixed and not subject to change.

– Hutchinson, 2015, p.258

Ethical Dilemma: a situation in which a choice must be made >2 potentially justifiable ethical choices. Examples:

• Eugenics
• Treatment for uninsured
• Allocation of health resources
• Right to refuse treatment, informed consent
• Involuntary commitment and insanity defense
• Rights of same-sex couples to adopt, insemination
• Gender reassignment
• Reproductive health for the intellectually disabled

-Hutchinson, 2015, p.259

Moral Distress: can occur when acting against one’s personal and professional values. Symptoms may include anger, anxiety, frustration, powerlessness, and fatigue.

Process of Making an Ethical Decision

• Step 1- Assessment (condition/problem, prognosis, socio-demographic information, advance directives, conflict or competing interests)
• Step 2- Identifying ethical issue (different morally acceptable options, rank the ethical or relevant considerations)
• Step 3- Goal setting, decision making, and implementation
• Step 4- Evaluation

About Moral Distress Project: core multidisciplinary experts discuss moral issues and distress from across the country in a documentary-style interviewing media project. The goal is to educate, inform, and de-stigmatize moral distress to help you, the viewer, process your own experiences and universalize the problem for an educational and validating experience. Also, earn free CE credit with The Moral Distress Education Project

Key Definitions Ethics

• Autonomy (Respect for): the moral principle that actions are ethically right if they comply with a person’s self-determined choice.
• Beneficence: the principle that actions are ethically right if they produce positive (good) outcomes.
• Benevolent Paternalism: intervention intended for the benefit of the patient/client/resident, usually without their express consent (and sometimes against their express objections), to prevent harm to the individual or others. Often the provider will justify the intervention on the basis that the condition being treated is impairing the person’s insight into the benefits of the treatment, and with treatment, the person’s true preferences will eventually be possible to determine and support.
• Bias: a frame-of-mind, perspective, point of view, or inclination. This can be affected by a person’s beliefs, values, educational or social background, assumptions, demographic characteristics, and life experiences. Bias is important to recognize and acknowledge because it affects one’s opinions and views on what is right and wrong and is highly influential in decision-making.
• Consequentialism: an ethical theory emphasizing the moral relevance of actual or likely consequences. By this theory, a decision with positive outcomes is ethically justified, while one that has negative outcomes is not ethically justified. The net benefits are considered when deciding whether something is right or wrong. Even if there are some negative consequences, the decision was “right” if there were more positive than negative effects.
• Decision-Maker: the person most responsible for making decisions in a situation of ethical uncertainty. In most health care situations, the patient/client/resident (or their authorized substitute decision-maker) is the decision-maker. Occasionally, there will be situations that do not directly affect or involve a patient/client/resident, in which case the decision-maker is the one who is most responsible for carrying out a decision.
• Deontology: an ethical theory emphasizing the role of rules, duties, and obligations in determining whether something is ethical or unethical. For deontologists, rationally derived rules (such as laws, policies, and codes of ethics) apply universally, irrespective of the possible outcomes of the decision. The right option is the one that is consistent with the rules.
• Dilemma: a problem that arises when there is a choice to be made, with no obvious reason to prefer one option over the other; a choice between two or more conflicting options, or a choice between two options that cannot both be carried out.
• Ethical Conflict: the tension that arises when a value judgment must be made, especially when two (or more) values must be weighed and ranked, and a decision made on which is most important in the situation.
• Ethics: the study of morality and moral life; a system for deciding what is right and what is wrong. A systematic way of evaluating values and actions.
• Fidelity: the ethical principle that action is ethically right if it involves keeping promises or commitments.
• Justice: the principle that action is ethically right if it treats people in similar situations equally.
• Moral Distress: the negative feelings that occur when one knows the right thing to do but is prevented from doing it through some barrier or constraint. This leads to the sense that one has compromised their integrity and can cause significant personal emotional reactions.
• Moral Residue: the negative feelings that arise from involvement in morally distressing situations, that can last for many years, and may manifest via physical, emotional and professional symptoms, including illness, anxiety, depression, and job turnover.
• Non–maleficence: the principle that actions are ethically right if they avoid producing bad consequences.
• Principles: rules or norms that guide behavior; often a starting point for considering ethical problems and may lead to more specific rules of conduct in some contexts.
• Relational Ethics: an ethical theory that situates ethical action in the context of the involved relationships. The emphasis is on how the context of a situation, including interpersonal commitments and connections, affects ethical decisions. This is especially important in care situations, as most health care decisions will be made in consideration of how they will affect the individual and those close to them, as well as the effects of and on the unique context within which the decision is being made.
• Stakeholder: the people and groups who will be affected by a decision; those who have a legitimate voice in the discussion. Different from decision-maker.
• Uncertainty: indecision, lack of clarity, when one is unsure of what the ethical problem actually is, and/or which values or principles apply in a situation. This often arises as a sense of something not being quite right, and there may not be anything concrete to suggest what it might be.
• Utilitarianism: an ethical theory emphasizing the consideration of the net good, measured by happiness, that is produced by a decision. A consequentialist theory, this view states that the decision that produces the most happiness is the most ethically justified.
• Values: a person’s individual perspective, opinions, beliefs, and views about what is important. Values guide actions by suggesting what is most important when decisions are made. Values are highly individual, and ethical conflicts often arise when values must be ranked in importance in order to decide the right thing to do.
• Veracity: the ethical principle that actions are right if they involve truthful communication and avoid dishonesty.
• Virtue Ethics: This ethical theory focuses on moral character and considerations of what a virtuous person might do in a given situation. This theory is often contrasted with rule- or consequence-based justifications.

–Ethical Decision-Making Framework © WRHA Ethics Services

References & Additional Information

Hutchinson, K. (2015). Psychiatric-mental health nursing: Review and resource manual. Silver Spring, MD: Nursing Knowledge Center.

Corey, G. (2016). Theory & practice of group counseling. Boston, MA, USA: Cengage Learning.

Read about Ethical Topics with Group Therapy

The Belmont Report: outlines 3 key ethical principles for conducting research with human subjects:  respect for persons, beneficence, and justice. Three primary areas of application involves informed consent, assessment of risks and benefits, and selection of subjects. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html

Declaration of Helsinki (DOH): One of the darkest episodes in the history of medical research – the horrific experiments carried out by doctors on concentration camp victims in Nazi Germany – was exposed at the Nuremberg trials of 1947. Emerging from the Nuremberg trials was a code of ethics setting out ‘standards to which physicians must conform when carrying out experiments on human subjects’. Hence, the DOH created by the World Medical Association (WMA) spells out a set of ethical guidelines for physicians and other participants in medical research and was described as the  ‘cornerstone’ document pertaining to medical research ethics and as ‘the most widely recognized source of ethical guidance for biomedical research’(NCBI).  https://www.wma.net/wp-content/uploads/2016/11/DoH-Oct2013-JAMA.pdf

Office of Human Research Protections (OHRP) full text of the HHS regulations for the protection of human subjects in research under 45 CFR 46; https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html. Read about the Institutional Review Board (IRB).