6.3 Ethical Dilemmas

Nurses frequently find themselves involved in conflicts during client care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.

An ethical dilemma can involve conflicting client’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.

Table 6.3a. Examples of Ethical Issues Involving Nurses

Workplace Organizational Processes Client Care
  • High client acuity
  • Inadequate staffing
  • Overuse of agency staff
  • Improper use of assistive personnel
  • Practicing beyond one’s scope of practice
  • Floating to other units without appropriate orientation
  • Horizontal violence/workplace bullying
  • Impaired coworkers
  • Violation of client privacy on social media
  • Paperwork and administrative task requirements
  • Substituting outpatient for inpatient care
  • Spending limits on care based on reimbursement codes for medical conditions
  • Discharging clients too soon and expecting family members to provide care
  • Reproduction Issues
    • Abortion
    • Birth control methods
    • Sterilization
    • Alternative conception
  • End-of-Life Issues
    • Physician-assisted suicide
    • Withdrawal of food/fluids
    • Withdrawal of life support
    • DNR/DNI
    • Full code despite a persistent vegetative state
  • Genetics
    • Screening
    • Stem cell research
    • Cloning
  • Organ transplantation
  • Client refusal of medications or treatments

Read more about Ethics Topics and Articles on the ANA website.

According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors[1]:

  • Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
  • An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements[2]
  • Knowledge of ethical principles and their application to ethical decision-making
  • Motivation and skills to implement an ethical decision

Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.”[3] See Figure 6.7[4] for an illustration of nurses’ moral courage.

Image of a shield shaped icon with the caduceus symbol between letters R and N
Figure 6.12 Moral Courage

Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.[5] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during client care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.

Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.[6] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.[7] Read more about self-care strategies to address feelings of burnout in the “Burnout and Self-Care” chapter.

Frameworks for Solving Ethical Dilemmas

Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.[8] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.

Nursing Process Model

The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.[9]

Table 6.3b. Using the Nursing Process in Ethical Situations[10]

Nursing Process Stage Considerations
Assessment/Data Collection
  • What is the issue?
  • Who is involved?
  • What are the facts (health status, pain, treatment)?
  • What are the stakeholder (client, family, health care team, community) concerns?
  • What ethics resources exist (such as an organization’s ethics committee)?
Assessment/Analysis
  • Analyze the facts and stakeholder values using ethical principles, ethical theories, the ANA Nursing Code of Ethics, or another ethical framework model.
  • Document the ethics resources consulted.
Diagnosis
  • Determine the care context and issues, including areas of agreement and conflict.
  • Consider the entire context, including the client, family, health care team, and institutional circumstances.
Outcome Identification
  • Establish a goal based on client autonomy.
Planning
  • Identify a range of options, realizing there may only be “best available” options when possibilities are limited.
Implementation
  • Ensure the option chosen is right, suitable, and appropriate. Be aware that not all options are appropriate in all contexts.
  • Implement the plan in collaboration with the client, family, and other stakeholders.
Evaluation
  • Evaluate what happened and what can be learned after every ethical dilemma.

Four-Quadrant Approach

The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.[11] See Table 6.3c for sample questions used during the four-quadrant approach.

Table 6.3c. Four-Quadrant Approach[12]

Health Care Indications

(Beneficence and Nonmaleficence)

  • What is the diagnosis/prognosis?
  • What are the goals of treatment/care?
  • What is the likelihood of success of treatment?
  • Will the proposed treatment plan benefit the client and avoid harm?
 Individual and Family Preferences

(Respect for Autonomy)

  • What are the client’s preferences?
  • Does the client understand their condition?
  • Has the client provided informed consent, and do they understand the risks and benefits of the proposed treatment?
  • Is the client competent and capacitated to make decisions? If not, are there advance directives in place?
Quality of Life

(Beneficence, Nonmaleficence, and Respect for Autonomy)

  • What is the probability of the client’s return to normal life with or without treatment?
  • Would the person experience any physical, mental, or social deficits even if the treatment succeeds?
  • Do the health care providers have any biases that might prejudice their evaluation of the client’s quality of life?
  • Has forgoing treatment been discussed?
  • Are there plans for comfort and/or palliative care?
 Contextual Features

(Justice and Fairness)

  • Are there family or provider issues, such as implicit bias, that might influence treatment decisions?
  • Are there religious, financial, social, racial, or legal issues that might affect treatment decisions?
  • Are there issues related to allocation of resources that might affect treatment?

MORAL Model

The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.[13],[14]

Table 6.3d. MORAL Model

M: Massage the dilemma Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal.
O: Outline options Generate several effective alternatives to reach the goal.
R: Review criteria and resolve Identify moral criteria and select the course of action.
A: Affirm position and act Implement action based on knowledge from the previous steps (M-O-R).
L: Look back Evaluate each step and the decision made.

PLUS Ethical Decision-Making Model

The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:

  • P: Policies, procedures, and guidelines of an organization
  • L: Laws and regulations
  • U: Universal values and principles of an organization
  • S: Self-identification of what is good, right, fair, and equitable[15]

The seven steps of the PLUS Ethical Decision-Making model are as follows[16]:

  • Define the problem using PLUS filters
  • Seek relevant assistance, guidance, and support
  • Identify available alternatives
  • Evaluate the alternatives using PLUS to identify their impact
  • Make the decision
  • Implement the decision
  • Evaluate the decision using PLUS filters
  1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  2. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/ ↵
  3. American Nurses Association (ANA). Ethics topics and articles. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ethics-topics-and-articles/ ↵
  4. “Moral courage.png” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0  ↵
  5. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  6. Norman, S. & Maguen, S. (n.d.). Moral injury. PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp ↵
  7. Dean, W., Jacobs, B., & Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. Annals of Emergency Medicine, 76(4), 385–386. https://doi.org/10.1016/j.annemergmed.2020.05.023 ↵
  8. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  9. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  10. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  11. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  12. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  13. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
  14. Crisham, P. (1985). Moral: How can I do what is right? Nursing Management, 16(3), 44. https://journals.lww.com/nursingmanagement/citation/1985/03000/moral__how_can_i_do_what_s_right_.6.aspx ↵
  15. Ethics & Compliance Initiative. (2021). The PLUS Ethical Decision Making Model. https://www.ethics.org/resources/free-toolkit/decision-making-model/ ↵
  16. Ethics & Compliance Initiative. (2021). The PLUS Ethical Decision Making Model. https://www.ethics.org/resources/free-toolkit/decision-making-model/ ↵
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