Heavy Burdens

Ethical Issues Faced by Military Nurses During a War

Deborah J. Kenny, PhD, RN, FAAN; Patricia Watts Kelley, PhD, FNP-BC, GNP-BC, FAANP, FAAN


Online J Issues Nurs. 2020;24(3) 

In This Article


Since the beginning of civilization, people have been involved in conflict and there have been nurses caring for individuals injured in these conflicts. Nurses have learned triage principles and have been educated about the types of injuries they might see. However, every war is different and there is no training for what nurses actually see or do and how they will process their feelings surrounding the circumstances. Most theory learned in nursing programs is "thrown out the window" when it collides with the reality of war. This does not imply that ethical concerns are set aside, but because of different expectations, they may become more acute and necessitate action that may not coincide with normal professional nursing values. This can create moral distress for nurses.

There is a large body of literature about the moral distress of nurses, but there seems to be a lack of clarity in how it is defined because of its multiple dimensions (McCarthy & Gastmans, 2015; Pauly, Varcoe, & Storch, 2012). Some literature discusses issues nurses may encounter in hospital situations (Bachhuber, Roberts, Metraux, & Montgomery, 2015; Hamric, 2012; McAndrew, Leske, & Schroeter, 2018; Oh & Gastmans, 2015; Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). Other literature discusses how moral distress occurs and what types of support nurses need (Burston & Tuckett, 2013; Rathert, May, & Chung, 2016). In many articles, the cause of moral distress is organizational (Corley, Minick, Elswick, & Jacobs, 2005; Wolf et al., 2016) and in others it is individual (Beck, 2011). Johnstone and Hutchinson (2015) contended that the lack of clarity regarding the concept may require nursing to abandon this concept and rethink moral reasoning in nursing.

Moral distress as a distinct concept in nursing is generally thought to have originated with Andrew Jameton's (1984) philosophical views of moral distress and ethical dilemmas. He defined moral distress as a clear difference in thinking between a nurse and those in superior positions, whereas an ethical dilemma involves a more global perspective of care and its context. He further differentiated distress into two distinct stages. The first is initial stress, where an individual recognizes there is dissonance between care needed and personal moral convictions. The second is reactive stress, where an individual will respond to the stressor with specific behaviors, which can either be short-lived, or persistent. Since his original writings, Jameton's philosophical thinking has evolved to a broadened concept that includes nursing within the global environment (Jameton, 2013). Prior to Jameton, moral distress in nursing was described by authors going back to Nightingale (1859/1992), where she stated,

The distress is very legitimate, but it generally arises from the nurse not having the power of laying clearly and shortly before the doctor the facts from which she derives her opinion, or from the doctor being hasty and inexperienced, and not capable of eliciting them. (p. 69)

Her notion seemed to be directly related to role differences between physicians and nurses. This was supported in a later article by Elmer (1909) concluding that well-trained nurses should be listened to, and held in high regard by physicians. He further stated that environment played a significant role in nurses' distress.

Moral distress as experienced by nurses is well documented and has been studied in multiple settings. However, it has rarely been studied with nurses in a war zone, during a war. While the root causes of moral distress that military nurses experience may remain the same as those described by Hamric et al. (2012), i.e., clinical situations, internal constraints, and external constraints, there are also significant differences in the types of stressors that deployed military nurses face. Fry and colleagues were among the first to begin to develop a model for moral distress in military nurses (Fry, Harvey, Hurley, & Foley, 2002). They described environments that were dangerous; patients who were uncharacteristic; and military triage practices that differed from the norm. They contended that this triad constituted a higher than normal probability for moral distress among military nurses.

Because the wartime environment is entirely distinctive, may be austere, and is often culturally different, ethical issues experienced by nurses may be even more pronounced (Gross, 2004). Moral distress in nurses and the psychological sequelae of war have been extensively studied, but there is a decided lack of literature surrounding ethical issues actually experienced by nurses in war. While there were numerous articles examining caring for patients in a war zone and on humanitarian missions, and these made mention of certain ethical challenges, only one other article from the United States could be found that specifically examined ethical issues of American nurses during war (Agazio & Goodman, 2017). This article will add to this gap by presenting a comprehensive view of ethical issues encountered by nurses in a war zone. The quotations presented are those that best exemplify the themes found in the data. In this article, group and individual participants are numbered in the order in which they appear in the discussion.