Common Examples of Ethical Dilemmas in Nursing
We all know the ancient Greeks were fond of contemplating everything in life. Plato, Socrates, Aristotle, Hippocrates, and many others posed some of the questions we are still seeking answers to, such as "How one ought to live?". This question is at the center of ethics, conveying centuries' worth of debate from scholars, writers, and other people as they go through life trying to make choices based on a set of moral principles, beliefs, and values that help us separate right from wrong and fulfill our duties.
A part of people's duties is also their profession. Many occupational fields are closely connected to moral and ethical values. In this article, we will be focusing on ethical issues and dilemmas encountered in the nursing field. So, read on and learn more about nurses' ethical awareness, ethical dilemmas in nursing, how one should deal with such predicaments, and what would happen if a nurse were to avoid their code of ethics.
A Nurse’s Code of Ethics
A Nurse's Code of Ethics is a collection of general guidelines or values written by the American Nurses Association (ANA) to inform all nursing professionals acting on their behalf on how they should conduct themselves. Such a code firmly states the association's morals, values, and priorities, which all nurses are expected to respect and uphold.
The Code of Ethics for Nurses with Interpretive Statements (the Code) is a pamphlet that establishes the ethical standards for nursing and provides a clear guideline regarding ethical analysis and decision-making. The Code consists of 9 provisions, interpreted below:
Provision 1 - Nurses must practice compassion and respect for every person's inherent dignity, worth, and unique attributes.
Provision 2 - Nurses' primary commitment is to the patient, whether an individual, family, group, community, or population.
Provision 3 - Nurses should promote, advocate for, and protect patients' rights, health, and safety.
Provision 4 - Nurses have authority, accountability, and responsibility for nursing practice, making decisions and taking action consistent with their obligations.
Provision 5 - Nurses owe the same duties to themself as they do to others.
Provision 6 - Through individual and collective effort, nurses should establish, maintain, and improve the ethical environment of their work setting and the conditions of employment.
Provision 7 - In all roles and settings, nurses should advance the profession through research and scholarly inquiry, professional standards development, and nursing and health policy generation.
Provision 8 - Nurses should collaborate with the public and other healthcare professionals to protect human rights, encourage health diplomacy, and help reduce health disparities.
Provision 9 - The nursing profession, collectively through its professional organizations, must articulate nursing values, maintain the profession's integrity, as well as integrate principles of social justice into nursing and health policy.
What Is an Ethical Dilemma In Nursing?
Regardless of the guidelines provided by the ANA, nurses still encounter situations where they have to make difficult choices between two or more options, neither of which is consistent with all the guidelines provided by the Nurse's Code of Ethics. When dealing with an ethical dilemma in nursing, these professionals must decide between two or more courses of action, which inevitably breaks part of their ethics code regardless of choice. Furthermore, ethical dilemmas may also cause a clash between a nurse's values outside of the Nurse's Code of Ethics.
The Most Common Reasons Why Nurses Face With Ethical Dilemmas
Ethical issues in nursing arise while caring for patients. There are various reasons why nurses come to face ethical dilemmas, with some of the most common ones being:
Patients refusing treatment, although the consequences of doing so could be fatal,
Tasks clashing with their personal beliefs,
Need for parental consent in children's treatment,
Involvement of minors in decision-making,
Contrasting values between nurses and patients,
Confidentiality in conflict with other ethical principles.
Common Examples of Ethical Dilemma in Nursing
The reasons listed above, combined with the nine provisions issued by the Nurse's Code of Ethics, lead to some typical ethical dilemmas in nursing examples that most nurses will encounter at least once during their careers.
Below, we will go through some common examples of ethical dilemmas in nursing where the treatment of patients is complicated due to a rise in conflict between the patient's rights and nursing obligations of care. Furthermore, we will include some ethical principles of nursing intended to help guide decision-making for nurses while ensuring the best outcome for the patient.
Pro-life vs. pro-choice
An ethical dilemma still highly debated in the United States is that between pro-life and pro-choice. Roe v. Wade, a landmark decision from the U.S. Supreme Court which stated that the Constitution of the United States protects a woman's freedom of choice regarding abortion, as of May 2022, is close to being repealed. Both sides have strong beliefs and arguments regarding why one option or the other should be protected by law.
However, when it comes to nursing, the dilemma arises when the law or a medical issue related to the patient constitutes one thing, whereas the patient demands something else. A typical scenario when such an ethical dilemma would arise is if patient A, who is pregnant, has a history of congenital heart defects. Due to the pregnancy, the risk of patient A worsening their condition is high. Furthermore, there can be a significant risk of the baby developing a heart condition, further complicating the birth. However, based on their religious beliefs, patient A is hesitant to have an abortion.
When asked about it, should the nurse advise the patient to proceed with the treatment necessary to save their life, or should they respect their personal choice? That is the pro-choice vs. pro-life dilemma.
Empirical knowledge vs. religious beliefs
It is common knowledge that we should respect people's religious practices. However, as a nurse, where do you draw the line when religious beliefs interfere with what is medically necessary to ensure their health? One of the most common scenarios when the empirical knowledge vs. religious belief ethical dilemma arises is when nurses are treating patients that are Jehovah's Witnesses. Their religious beliefs do not permit such patients to accept a blood transfusion.
But what if a patient needs a blood transfusion in order to live? Once again, should you as a nurse proceed with what you have been trained to do and ensure the patient is safe and healthy, or respect their wish? Well, that's the whole dilemma.
Generally, if the patient is conscious and aware of the consequences of refusing the transfusion, there is not much you can do. Ensure you are very thorough with your medical explanations of their condition and keep detailed documentation regarding their refusal of treatment.
Autonomy vs. beneficence
Yet another instance when a nurse has to decide whether they should proceed with a necessary treatment that the patient is opposed to is explored in the autonomy vs. beneficence nursing ethical dilemma.
Imagine this: one of your patients was diagnosed with stage IV cancer, and the doctors have concluded that there is nothing they can be done to help them. All the medics can offer at that stage is medication to ease the patient's excruciating pain while they rest at home. However, the patient refuses to be given said medication since it makes them weak and drowsy while they want to be awake to spend their last days with their loved ones. The patient's family members plead for you as a nurse to somehow administer the medication without the patient's knowledge since they can tell the pain is agonizing. What should you do?
Of course, as difficult as it is for the patient's family members to see their loved one in pain, as a nurse, you are obliged by the Code to obey the patient's wishes as long as they are aware of their state when making the decision.
Parent refuses to vaccinate their child
Although vaccination has been proven to be an effective way to prevent various diseases, many people in the United States and worldwide are reluctant and refuse vaccination altogether. The dilemma of allowing adults to make decisions that could harm themselves is mild compared to when nurses have to work with parents who refuse to let their children be vaccinated.
As a nurse, you can't go against the guardian's wishes for their children. All you can do is provide as much information as possible to ensure the parents are well aware of what their decision means for the child. Unless it is required by law that the child be vaccinated against a specific disease, then having the parents sign a document stating their stance is all you must do.
Being honest vs. withholding information
The power of honesty to help foster trust between patients and healthcare professionals is grand. We are always taught to be truthful, but what if you feel like you will be causing more harm than good by being honest? A simple scenario showcasing the being honest vs. withholding information ethical dilemma is if patient B is not doing well dealing with a specific health problem. As their nurse, you feel like thoroughly explaining the gravity of their condition will cause their anxiety and worry to rising, thus worsening their mental health.
However, unless there is scientific proof that knowing the truth will cause a terrible impact that can be lethal for patient B, you are forced to be truthful and not withhold anything from your patient. As difficult as it is to pick one side, your position requires you to choose the "honesty" side when encountering such a dilemma.
Healthcare needs vs. resource allocation
Nurses are supposed to treat each patient as equal, providing care to each one. However, unfortunately, in some cases, they have to choose which one deserves or is in more need of treatment than the other. The healthcare needs vs. resource allocations ethical dilemma in nursing examples relate to a shortage of resources that would provide the nurse with the means necessary to obey the rule of giving equal care to everyone.
Imagine this: you are a nurse caring for and administering medication to a dozen people. However, you are informed that there is a shortage of a specific prescription needed by all patients. What to do then?
The best-case scenario would be if you could safely substitute the medication with another one. However, even then, you would have to choose which patients are in more need of the proper medication right then and there.
Personal and professional boundaries
Keeping our personal and professional lives separate is sometimes easier said than done. As a nurse, you will be well-liked for helping change people's lives, and sometimes, your patients or their family members will seek a friendship with you.
A typical scenario in today's age where technology makes it so easy to find people and create links will be if a patient, former patient, or even relative of theirs follows you on social media. The action seems harmless enough. However, are you, as a nurse, allowed to create connections that lie beyond the nurse-patient spectrum? Generally, the answer is no.
It is OK to greet back a patient, ask them how they are doing and answer similar questions. Still, it is entirely different from establishing a personal relationship with them when they are part of your professional life.
End-of-life decision-making
In some cases, when patients suffer from a terrible disease or injury that ensures very little time before death, patients might decide to suspend specific treatment and resuscitation techniques. As hard as it is to respect one's wishes to give up fighting for their life, as a nurse, you must comply with their wishes.
The end-of-life decision-making dilemma reaches its pinnacle when the patient's heart stops beating regularly. At that point, as a healthcare professional, you have to choose between going with your instinct of performing resuscitation and continuing with life-sustaining treatment or letting the patient die as per their wish. In such cases, the patients' sign DNRs which are requests not to have professionals such as you perform CPR when needed. The DNR is included in their medical chart, and you must respect it.
Science vs. spirituality
The spiritual and scientific side of life is quite different yet complementary to each other. Similarly, the two help one another in medicine, as research has confirmed that spiritual practice can positively impact medical value. That, however, is not always the case. When patients are too focused on their spiritual beliefs, they refuse to acknowledge the scientific facts you present to them.
As a nurse, you will have to deal with ethical dilemmas regarding the spiritual vs. scientific approach of your patients, their family members, and loved ones regarding their medical condition. What should you do if family members of patient X, who scientifically has little chance of surviving an operation, refuse to recognize the risk due to their spiritual belief that everything will be going well?
According to the Nurse's Code of Ethics, you must respect all your patients' beliefs and religious practices. So, even if you disagree with their thoughts and feel frustrated when they ignore your warnings and explanations of the potential danger, you are obliged to support their decision.
The patient does not have an advanced directive
We have had many cases when ethical dilemmas were dealt with simply by respecting the patient's wishes. However, that is not always possible. A scenario when nurses might have to go against the patient's wishes is when they don't have an advanced directive.
Visualize this scenario: You are caring for an 80-year-old male patient with muscular dystrophy. One day, he mentions that he has grown tired of dealing with the disease, and when the time comes, he would not like to be resuscitated. However, he loses consciousness before he can sign on for an advanced directive, including a DNR.
Although you are aware of the patient's wishes, without an advanced directive, in most cases, the power to decide how treatment continues lies with one of the patient's family members.
Duty and compassion do not align with facility safety protocols
Most nurses are drawn to their job because of a desire to help people in need, so it is no surprise that they are compassionate people who try their best to ease their patient's suffering. However, in an attempt to help their patients, they might find themselves in situations where their duties and the facility's safety protocols do not permit them to act on their feelings.
A simple example to illustrate this would be if you, as a nurse, look after patient Y, who is suffering from a deadly viral virus. They do not have any family left. Therefore, you made a promise that you would not leave them alone. A few days later, you are moved from the sector where patient Y is, and due to safety protocols, you are not permitted to revisit them.
As difficult as it is to know you have broken part of your moral code by not staying true to your word, it is for the greater good. Safety protocols are created with healthcare in mind, and you can explain the situation to another nurse in charge of the sector where patient Y is placed so that they can ensure the patient they are not alone.
Questionable medication orders
No person is perfect. Even doctors who are highly trained can sometimes overlook something and make mistakes. The good thing about working in facilities with so many healthcare workers focusing on different aspects of medical care is that one order goes through many people. What the doctor did not notice, a nurse might.
Although nurses are taught to follow the orders issued by physicians, an ethical dilemma may arise when you are unsure if the medical order prescribed by the doctor is the best one. It could be an allergy, complications with an already-existing medical condition, or some other element that pushes you to act on behalf of the patient's benefit and question the doctor's medical order.
Never be afraid to raise your voice for your patients and do everything to ensure that they get the best treatment possible. The doctor will most likely appreciate your thoughtfulness and attention to detail which prevented a mistake from happening.
How to Deal With Ethical Dilemmas in Nursing
As you might have seen from some of the "solutions" provided in the ethical dilemma in nursing examples listed above, often, the best course of action is to put the Nurse's Code of Ethics before what you deem to be the right choice influenced by emotions and feelings.
Professionals who have dealt with the same dilemmas have pondered the right thing to do and came up with the code's provisions that you are obliged to follow. In cases when even the code is challenged, remember always to respect the patient's wishes and stick by the book, ensuring everything is well-documented, and everyone is well-informed.
Consequences of Avoiding Ethical Dilemmas in Nursing
You might think that the best way to ensure you do not violate the nurse's ethical code is by avoiding ethical dilemmas altogether. However, that is not true. If you try to avoid ethical dilemmas, you will most likely face discipline from your supervisor or, in extreme cases, even a lawsuit which can lead to loss of licensure. On top of it all, you will be stressing yourself out more trying to avoid the dilemma than outright speaking to your patient and healthcare staff about finding a solution.
So, remember that ethical dilemmas are part of the job, and as long as you prioritize the welfare and comfort of your patients, you will find a solution.
Our Final Thoughts
Nursing and ethical dilemmas come hand-in-hand, so whether you are an aspiring nurse reading about challenges you might face or a licensed nurse wondering if they are the only ones dealing with such puzzles, know that you are not alone. You do not have to carry all the burden. Seek support and advice to make coping with such dilemmas easier.
At its core, overcoming ethical dilemmas is as easy as ABC, as all you have to keep in mind are:
A - Autonomy,
B - Beneficence,
C - Confidentiality,
D - Do not harm ,
E - Equity.