2.5 Ethical Practice and Decision-Making
Key Takeaways
- Autonomy is the client's right to self-determination, including refusing care; on the NCLEX it usually outweighs the nurse's or family's preferences for a competent client
- Beneficence (do good) and non-maleficence (do no harm) together justify safety checks, error reporting, and least-restrictive interventions such as trying alternatives before restraints
- Justice requires prioritizing by clinical need and treating all clients equitably regardless of background or likability
- An ethical dilemma is a conflict between two valid principles (e.g., autonomy vs. beneficence) — distinct from a legal violation, which has a clear right answer
- When a dilemma exceeds the LPN's authority, consult the supervising RN and request an ethics committee consultation rather than acting unilaterally
Core Ethical Principles
When statutes and policies do not dictate the answer, ethical principles guide the nurse. NCLEX-PN items frequently ask you to name the principle that applies to a scenario, so internalize each definition.
| Principle | Definition | Bedside application |
|---|---|---|
| Autonomy | Right to self-determination | Respect a competent client's choice even if you disagree |
| Beneficence | Duty to do good | Provide timely, competent care; advocate for needs |
| Non-maleficence | Duty to avoid harm | Check meds, follow safety protocols, report near-misses |
| Justice | Fairness and equity | Prioritize by clinical need, not personal preference |
| Veracity | Truthfulness | Answer honestly within scope; no false reassurance |
| Fidelity | Faithfulness | Keep promises; maintain confidentiality |
Autonomy in Practice
Autonomy means honoring the client's right to decide about their own body. A competent adult may refuse any treatment, even one that is life-sustaining, even if death may follow. Supporting autonomy includes giving information so choices are informed, respecting a refusal, and backing a client whose decision differs from yours or from the family's.
| Situation | Autonomous, ethical response |
|---|---|
| Client refuses recommended surgery | Confirm understanding of consequences, respect the decision |
| Client wants to leave against medical advice (AMA) | Notify RN, document that risks were explained |
| Family disagrees with the competent client's choice | Support the client's expressed wishes |
Beneficence vs. Non-maleficence
These paired duties are constantly balanced. Restraints are the classic NCLEX example: they may prevent a fall (beneficence) but cause injury and loss of dignity (maleficence), so the nurse must try the least-restrictive alternative first and apply restraints only with a current provider order and close monitoring. Similarly, opioids relieve suffering (good) yet risk respiratory depression (harm), requiring sedation monitoring.
Justice, Veracity, and Fidelity
Justice means allocating care and resources by clinical need, never giving better care to clients you find easier or more likable, and never treating someone differently because of race, religion, or lifestyle. Veracity means truthful communication — answer honestly within your scope, refer beyond-scope questions to the RN/provider, and never offer false reassurance. Fidelity means keeping promises and protecting confidentiality, including honoring a client's request not to disclose a diagnosis to family.
Ethical Dilemmas vs. Legal Violations
An ethical dilemma is a conflict between two valid principles where no option is clearly right — unlike a legal violation, which has a definite correct action. Recognize the competing principles, then escalate appropriately.
| Dilemma | Principles in conflict |
|---|---|
| Client refuses life-saving treatment | Autonomy vs. beneficence |
| Truth may cause emotional distress | Veracity vs. non-maleficence |
| Scarce resource, several clients need it | Justice vs. beneficence |
| Family wants information withheld from client | Fidelity to client vs. family wishes |
How the LPN/LVN navigates a dilemma
- Recognize the conflicting principles.
- Gather the full clinical and social picture.
- Consult the supervising RN — do not act unilaterally.
- Request an ethics committee consultation for end-of-life, futility, or unresolved family conflicts.
- Default to respecting the competent client's autonomy.
Professional Boundaries
Maintain a therapeutic, not personal, relationship. Do not accept gifts of significant value, share your own personal problems, befriend clients on social media, or show favoritism. Reporting a coworker who skips hand hygiene is grounded in non-maleficence — protecting clients from preventable infection outweighs loyalty to a colleague.
Telling Ethics, Law, and Scope Apart
Students lose points by confusing three overlapping but distinct frameworks. A quick triage on each item:
| Framework | The question it answers | Signal in the stem |
|---|---|---|
| Ethics | What is the right thing when principles conflict? | Two defensible choices, no clear rule |
| Law | What is required or prohibited? | A statute, mandatory report, or liability |
| Scope | Who is permitted to do this task? | RN vs. LPN vs. UAP role question |
If a stem has a clear legal duty (report abuse, do not commit battery), it is a law question even if it feels ethical. If two principled options exist (autonomy vs. beneficence), it is an ethics question, and the answer usually consults the RN or honors autonomy.
Worked Scenario: Truth-Telling Within Scope
A client asks the LPN, "Do I have cancer?" when the biopsy result is in the chart but the provider has not yet disclosed it. Veracity forbids lying, but disclosing a diagnosis is outside the LPN's scope and is the provider's responsibility. The exam-correct response neither confirms nor denies the result and instead acknowledges the client's worry and arranges for the provider/RN to speak with them — for example, "You sound worried about the results. I'll let your provider know you have questions and ask them to come talk with you." This honors veracity (no false reassurance), respects scope, and supports the client emotionally.
Whistleblowing and Impaired Colleagues
Ethics and patient safety can require reporting a peer. A nurse who appears impaired (alcohol, diverted controlled substances), who falsifies documentation, or who repeatedly breaches safety must be reported through the chain of command — first the supervisor, then the BON if required. The driving principles are non-maleficence and fidelity to the public the license protects. Many states offer confidential alternative-to-discipline programs for impaired nurses, reflecting beneficence toward the colleague while still protecting clients.
High-Yield Reminders
- For a competent client, autonomy usually wins over beneficence and family wishes.
- Try the least-restrictive option before restraints — a non-maleficence application.
- True dilemmas are escalated to the RN or ethics committee, not solved unilaterally by the LPN.
A competent client with heart failure decides to stop all medications against medical advice. What is the most appropriate LPN action?
An LPN observes a coworker repeatedly skipping hand-hygiene protocol. Which ethical principle most directly supports reporting this behavior?
A client asks the LPN not to reveal her cancer diagnosis to her family. The family later asks the LPN directly about the diagnosis. What should the LPN do?