16.1 Nursing Ethics & Patient Advocacy
Key Takeaways
- The six core ethical principles are autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity — the exam tests them through clinical scenarios, not definitions
- Moral distress occurs when the nurse knows the right action but is constrained from taking it; unresolved, cumulative moral distress contributes to moral injury and burnout
- The ANA Code of Ethics for Nurses contains 9 provisions; Provision 3 (protecting patient rights, health, and safety) is the anchor for advocacy questions
- A competent adult has the right to refuse any treatment, even if refusal leads to death — the nurse's role is to ensure the decision is informed, not to persuade
- Ethics committees provide consultative recommendations, not binding orders; any clinician, patient, or family member can usually request a consult
Ethics questions on the MEDSURG-BC exam rarely ask you to define a principle — they place you in a clinical scenario and ask what the nurse should do first or which principle is in conflict. Learn the principles as actions, and learn the correct nursing response patterns.
The Six Ethical Principles
| Principle | Meaning | Clinical Example |
|---|---|---|
| Autonomy | Respecting the patient's right to self-determination | Honoring a competent patient's decision to decline a recommended blood transfusion |
| Beneficence | Acting in the patient's best interest; doing good | Turning and repositioning an immobile patient to prevent pressure injury |
| Nonmaleficence | Doing no harm | Double-checking a high-alert medication dose before administration |
| Justice | Fair, equitable distribution of care and resources | Triaging patients by acuity rather than by social status or ability to pay |
| Veracity | Truth-telling | Answering a patient's questions about a new diagnosis honestly within the nurse's scope |
| Fidelity | Keeping promises and commitments | Returning to reassess pain at the time you told the patient you would |
Exam scenarios often pit two principles against each other. A family asking you to withhold a terminal diagnosis from a patient creates conflict between veracity (telling the truth) and perceived beneficence (protecting the patient from distress). A competent patient's refusal of life-saving surgery creates conflict between autonomy and beneficence — and autonomy wins for the competent adult.
Ethical Dilemma vs. Moral Distress vs. Moral Injury
These three terms are frequently confused and frequently tested:
- Ethical dilemma — a situation where two (or more) ethical principles conflict and there is no clearly right answer. Example: continuing aggressive chemotherapy that is causing suffering but that the patient's family demands while the patient is ambivalent.
- Moral distress — the nurse knows the ethically correct action but is constrained from taking it by institutional, legal, or hierarchical barriers. Example: a nurse believes a dying patient needs more aggressive comfort measures but the provider will not order them. Classic signs: frustration, anger, guilt, feeling powerless.
- Moral injury — the deeper, lasting harm that accumulates from repeated moral distress or from participating in (or witnessing) acts that violate one's moral code. It contributes to burnout, compassion fatigue, and intent to leave the profession.
Pearl: if the stem says the nurse "knows what should be done but cannot do it," that is moral distress, not an ethical dilemma. A dilemma means the right course itself is genuinely unclear.
ANA Code of Ethics for Nurses
The American Nurses Association (ANA) Code of Ethics for Nurses contains 9 provisions with interpretive statements. Know the themes:
- Provisions 1–3 describe the nurse's fundamental values and commitments: practicing with compassion and respect for the inherent dignity of every person (1); primary commitment to the patient, whether individual, family, group, or community (2); and promoting, advocating for, and protecting the rights, health, and safety of the patient (3). Provision 3 is the advocacy provision — it also covers protection of research subjects and impaired practice reporting.
- Provisions 4–6 address accountability, duties to self, and the work environment: authority, accountability, and responsibility for one's own practice (4); duties to self, including integrity, competence, and continuing growth (5); and maintaining and improving the ethical work environment (6).
- Provisions 7–9 address the profession's broader obligations: advancing the profession through research and scholarship (7); collaborating to reduce health disparities (8); and shaping social justice and health policy through professional organizations (9).
The Code is non-negotiable: it applies in every setting and cannot be overridden by employer policy.
Patient Advocacy in Practice
Advocacy means acting on behalf of the patient to protect rights, support informed decision-making, and speak up against unsafe or unethical care. Concrete advocacy behaviors the exam rewards:
- Protecting rights — ensuring privacy, confidentiality, informed consent, and the right to refuse.
- Speaking up — questioning an order that appears unsafe, using the chain of command when a concern is dismissed (charge nurse → house supervisor → provider leadership → administration). Document each step.
- Supporting informed decisions — giving patients accurate, unbiased information, clarifying (not deciding for them), and connecting them with resources such as palliative care, social work, or chaplaincy.
- Supporting the decision the patient makes — once a competent patient makes an informed choice, advocacy means defending that choice, even when you disagree with it.
Ethics Committees and Consults
Hospital ethics committees are multidisciplinary (physicians, nurses, social work, chaplaincy, legal, community members) and serve three functions: developing policy, providing education, and conducting case consultations. A consult can typically be requested by any member of the healthcare team, the patient, or the family. The committee offers recommendations, not binding rulings — it facilitates communication and clarifies values when the team and family are deadlocked. The nurse's role is to identify the ethical conflict early, suggest the consult, and help the patient and family articulate their values.
Common Tested Dilemma Scenarios
- End-of-life decisions — A competent, informed patient may refuse or request withdrawal of life-sustaining treatment (ventilator, dialysis, artificial nutrition). Withholding and withdrawing treatment are ethically and legally equivalent. Palliative medications given to relieve suffering are ethically justified under the principle of double effect — the intent is comfort even if a foreseeable side effect is hastened death.
- Refusal of treatment — verify competence and understanding, ensure the patient has complete information, notify the provider, document, and support the decision. Never coerce or manipulate.
- Scarce resources — justice governs allocation: distribute by need and likely benefit using consistent, transparent criteria, never by social worth, payer status, or personal favoritism.
Decision-Making Frameworks
When a scenario has no obvious answer, apply a structured process: gather the relevant facts (medical, psychosocial, legal), identify the ethical problem and the principles in conflict, explore options and their consequences, act on the best option, and evaluate the outcome. The mnemonic MORAL (Massage the dilemma, Outline options, Review criteria and resolve, Affirm position and act, Look back) is a formalized version. On the exam, answers that involve gathering more information, clarifying the patient's wishes, and using available resources (ethics consult, palliative care) almost always beat answers that involve acting unilaterally or judging the patient.
A nurse on a medical-surgical unit believes a terminally ill patient needs larger doses of opioid for comfort, but the provider refuses to increase the order despite the nurse's repeated concerns. The nurse feels frustrated and powerless because she knows what should be done but cannot act. This experience is best described as:
A competent 78-year-old patient with metastatic cancer tells the nurse, "I've decided I don't want to be put back on the ventilator if my breathing fails again." The patient's son insists everything possible must be done. Which action by the nurse best demonstrates advocacy?
A nurse administers pain medication at the exact time promised and returns to reassess the patient as agreed during report. This behavior best exemplifies which ethical principle?