Ethical Awareness: What It Is and Why It Matters

Aimee Milliken, PhD, RN


Online J Issues Nurs. 2018;23(1) 

In This Article

Ethical Awareness: Everyday Scenarios

Even everyday clinical situations require careful consideration of ethical risk. Though the risk may seem low at the outset, the following scenarios highlight the way that even routine situations can have profound ethical implications for patients. While there are many ways to conduct an ethical analysis, the focus here will be on the four primary ethical principles foundational to nursing practice (defined above) and how they relate to the scenarios. For the purpose of illustration and discussion, these scenarios assume nurses who could benefit from a higher level of ethical awareness, to include potential everyday challenges, as opposed to higher profile cases more commonly discussed in the literature (e.g., initiation of feedings/ventilation).

Scenario one

Mr. M is an 85-year-old man admitted to the neurological intensive care unit (ICU) after developing a subdural hematoma due to a recent fall. Mrs. M (his wife) asks to spend the night in her husband's room, as she is concerned he may become distressed if she leaves. The rules in the ICU prohibit family members from staying overnight, unless the patient is actively dying. Citing this rule, John, the ICU nurse, sends Mrs. M home. Overnight, Mr. M becomes acutely agitated, requiring wrist restraints and repeated doses of intravenous sedatives.

This case suggests several possible ethical concerns. First, it appears as though John, the nurse, has acted based on routine. In this sense, we may be concerned that John has not fully considered Mr. M's possible unique interests in this case. This relates to John's ethical obligation to promote Mr. M's autonomy, and involves considering the question: what would be best for Mr. M, given his clinical situation and what we know about his goals and values? A second ethics-related concern has to do with John's obligation to promote good (beneficence) and to prevent harm (non-maleficence). The harm, in this case, would be Mr. M's increase in agitation and the possible need for restraints and sedation.

Ethical awareness would have helped John to recognize the range of potential ethical implications of his decisions as they relate to the aforementioned concerns. In other words, ethical awareness would enable John to have a more holistic view of Mr. M's predicament and may allow him to develop a plan of care more in line with this view. In a patient such as Mr. M, with a neurological injury, minimizing the need for sedation and restraints is preferable, both ethically and clinically, as any change in neurologic status may be cause for concern.

In viewing the situation with this lens, John may have decided to let Mrs. M stay, despite the unit routine, thus promoting Mr. M's autonomy. This decision also aligns with John's obligations related to beneficence and non-maleficence. Allowing Mrs. M to stay on the unit may minimize the risk of agitation if her presence helped soothe her husband. This action may have successfully prevented use of more restrictive measures (i.e., restraints and sedation), thereby promoting a better outcome (beneficence) and mitigating potential harm.

Scenario two

Mr. L is a 50-year-old man admitted for gastrointestinal (GI) bleeding. After a couple of days his hematocrit is still low and his physician tells him that he is not ready to be discharged today. Mr. L becomes angry and tells the team he wants to leave against medical advice (AMA). His nurse, Susan, and his physician outline the risks of leaving, including the risk of rebleeding, but he insists and leaves the hospital. That night, Mr. L ends up back in the Emergency Room with profuse GI bleeding.

While leaving AMA is often viewed as a patient right based on the principle of autonomy, it is also necessary to consider whether the patient is putting himself at undue risk for harm. When the risks of a situation outweigh the possible benefits, the provider's obligation to promote the patient's best interests may outweigh the patient's desire to act autonomously (Grace, 2014). Thus, the ethics worry in this case relates to the potential conflict between Susan's ethical obligation to promote good (beneficence) and Mr. L's right to autonomy.

To promote Mr. L's ability to act autonomously in the future, it is necessary to minimize the potential harm to which he exposes himself in the present. Ethical awareness would help Susan recognize this responsibility. To address this obligation, Susan could try to talk through the situation in greater depth with Mr. L in an effort to uncover the reasoning behind his desire to leave. There may be additional factors of which Susan is unaware that are contributing to Mr. L's anger. If these reasons are explicated, perhaps they can arrive at a compromise to appease Mr. L, while keeping him medically safe.

Additionally, Mr. L's clinical picture includes a low hematocrit. This factor may be negatively impacting his decision-making abilities. Susan may wonder whether Mr. L is truly making an autonomous decision, which would require that he fully understands and is able to use reason to determine the potential long-term outcomes of leaving the hospital. Susan could further explore these concerns to ensure that Mr. L's decision to leave is actually fully informed. Should she reach an impasse, she may consider seeking additional resources to keep Mr. L safe, including involving psychiatry and possibly an ethics consult.

Scenario Three

Emily is a new nurse on a medical-surgical unit. She has a busy assignment, and is behind on documentation. She has her patients' vital signs on a piece of paper in her pocket but has not written them in the chart. However she is happy to see her hypertensive patient, Mrs. O, is now normotensive.

The medical team rounds on Mrs. O without Emily, and sees that the most recent blood pressure (BP) documented in the chart is still elevated. They order an increase in Mrs. O's antihypertensive medications, not realizing her BP is has now normalized (since Emily has not yet charted it). In an effort to help Emily catch up, a nurse colleague gives Mrs. O the new dose of medication. An hour later Mrs. O becomes diaphoretic and dizzy. When Emily rushes in to re-check her blood pressure, she is hypotensive.

Because Emily was behind, the plan of care was changed based on old data, putting Mrs. O in a dangerous situation. Though Emily had good intentions, her patient was given an improper dose of medication. Using ethics-language, Emily was unable to provide beneficent (good) care, and her patient suffered a potential harm. Nurses often fall behind during the course of a shift; this is a reality of practice. However, this scenario demonstrates that even something as simple and routine as charting vital signs has potential ethical implications. Falling behind, and being unable to perform necessary duties, can result in potential harm.

An additional ethics worry is that Emily was so busy that she missed rounds with the medical team. This means Emily did not have the ability to fully update the team about Mrs. O's progress and to raise any potential concerns or considerations for the plan of care. This represents a lost opportunity to advocate for her patient. Advocacy is an important component of the duty to promote autonomy, particularly when patients are in a position where they cannot make their own needs or wishes known, or when patients may not have all the necessary information to make informed decisions.

Ethical awareness would have helped Emily recognize that, based on her duty to promote good (beneficence), to advocate for her patient (autonomy), and to prevent harm (non-maleficence), she has an ethical obligation address the situation that is leading to her busyness. The inability to meet her patient's needs may result in possible harm, as Mrs. O experienced. This is not only a clinical problem or a possible bad outcome; this is fundamentally ethical in nature. This recognition may help Emily feel more confident in asking for help. Ethical awareness also may prompt Emily to evaluate the root cause of this issue, so that she (and possibly others) could avoid similar circumstances in the future.