LEGAL AND ETHICAL ISSUES IN NURSING

In a health care setting, the patient is at core of nursing practice. Professional nursing allows the nurse to
practice the essence of nursing while recognizing that all patients have intrinsic value. Achieving and
staying true to professional nursing values while practicing in the health care setting can create a unique
set of ethical, legal and professional issues for the nurse.

Legal aspects of nursing / Laws applicable for nursing practice

Nursing Professionals and caregivers who do their best to perform the requirements of their jobs make
decisions or complete tasks that can result in legal action being initiated against them by clients / patients
or their relatives. The concerned, informed, dedicated professional always strives to implement the
education and competency to successfully accomplish all tasks, treatments, and responsibilities correctly
and accurately. However, there are rare instances when regardless of the application of the most strict
standards for quality care, variations occur which result in litigation. To help avoid these instances, it is
important to be educated and informed about current laws, statutes, and standards. Knowledge on legal
aspects related to nursing profession is absolutely essential for every nurse to safeguard self and clients
from legal complications. Hence, it is essential that every professional nurse must be aware and familiar
with some of the following legal terms -
 Law: means a body of rules to guide human action. Rules of conduct, established and enforced by
authority, which prohibit extremes in behavior so that one can live without fear for oneself or one’s
property.
 Common Law: created by judicial decisions made in courts when individual cases are decided.
 Criminal Law: is a part of public law which covers Judicial Act that are illegal and against the law. It
Prevent harm to society and provides punishment for crimes.
 Assault: is an intentional tort. Assault occurs when a person puts another person in fear of
harmful or offensive contact. In other words, it is a willful threatening to touch another
person without their consent. The victim fears and believes that harm will result as a result
of the threat.
 Battery: is an intentional touching of another’s body without their consent.
 Fraud: is an intentional or a deliberate deception that results in unlawful gains.
 Civil Law: protects the rights of individual person within our society and encourages fair and
equitable treatment among people. The tort is one of the civil law related to nursing practice.
 Tort: is a civil wrong made against a person or property. A tort can be; the denial of a person’s
legal right, the failure to comply with a public duty, the failure to perform a private duty that results in
harm to another. Tort is a civil law that addresses the legal rights of patients, and the responsibilities
of nurse in terms of Nurse Patient Relationship. Some torts specific to nursing and nursing practice
include things like malpractice, negligence, assault, battery violations relating to patient confidentiality
etc. there are two categories of torts. They are; unintentional torts and intentional torts.
 Unintentional Torts: is an unintended accident that leads to injury, property damage, or financial
loss. In the event of an untended tort, the person who caused the accident did so inadvertently and
typically because they were not being careful (negligence). Tort has two categories; they are -.
1. Negligence: is an unintentional tort. It occurs when the nurse fails to follow established
policies, procedures and standards of care in the same manner that another "reasonable" nurse
would do in the same situation. In other words, it is conduct that falls below the standard of
care that a reasonable person ordinarily would use in a similar circumstances or it is described
as lack of proper care and attention carelessness.
2. Malpractice: is an unintentional tort. It is failure to meet the standards of acceptable care
which results in harm to another person. It has six elements. They are; (1) a duty, (2) breach of
duty as a nurse, (3) reasonable foreseeability that the nurse's act has a connection with the
patient injury that occurred, (4) the patient was harmed, (5) the link that act directly led to the
harm and (6) the patient has the right to financial compensation or damages.

 Intentional Torts: any intentional acts that are reasonably foreseeable to cause harm to an
individual and that do so. The intentional tort includes; false imprisonment, assault, battery, invasion
of privacy & confidentiality, false imprisonment, fraud, and an intentional infliction of emotional
distress.
 False Imprisonment: occurs when a client is not allowed to leave a health care facility when
there is no legal justification to detain the client or when restraining devices are used
without an appropriate clinical need. In simple words, it is restraining, detaining and/or
restricting a person's freedom of movement or/ using a restraint without an order is
considered as false imprisonment.
 Invasion of privacy & confidentiality: includes violating confidentiality intruding on private
client or family matters, and sharing client information with unauthorized persons.
 Nurses Rights in Indian
Some of the rights and responsibilities applicable for nurses are -
1. Right to refuse to treat patient except in case of an emergency. (Though it can be debatable as
patient should not ideally be refused for treatment but in certain scenario nurses hold this right)
2. Right to sue for fee
3. The right to add a title or descriptions to one’s name. Any title, description, abbreviation or letter
which implies holding a degree, diploma, license or certificate showing particular qualification
4. The right to set standards for excellence in nursing
5. The right to participate in policy making affecting nursing
6. Rights to work and serve in a safe and health work environment
7. Right to refuse or protest formally a physician’s order if a nurse believes it is harmful for the client
8. Right of appointing and assigning
9. Right of quality control
10. Right for record keeping
11. Right to care public
12. Right of using equipment’s
13. Right for observation and reporting

Patients Rights in India

The Ministry of Health and Family Welfare (MoHFW) has recently released a ‘Charter of Patients Rights’
that compiles the lawful rights as stated in the Constitution of India. The list of Patients Rights is –
1. Right to Information: Physicians or their qualified assistants are required to provide adequate
information about your illness, its diagnosis (provisional or confirmed, as it may be), proposed
investigation and possible complications to the patient (If the patient is not in a state to understand this,
the information to be given to caretaker). Apart from this, patients have the right to know the identity and
professional status of every doctor / treating doctor, and information regarding costs of treatment.
2. Right to records and reports: Patients or their respective caretakers have the right to access the
originals or copies of case papers, indoor patient records and investigation reports. Investigation reports
have to be made available to them within 24 hours of admission or 72 hours of discharge.
3. Right to emergency medical care: In an emergency situation, one can avail medical care in any
government or private hospital. Under Article 21 of the Constitution, which ensures that every person has
the right to life and personal liberty, and one has the right to prompt emergency care by doctors without
compromise on quality or safety and without having to pay full or an advanced fee to the hospital.
4. Right to informed consent: If a hospital decides upon carrying an invasive investigation or surgery or
chemotherapy on a patient, they require doing so after completing an appropriate policy procedure. The
doctor primarily in charge of a patient has to explain the risks, consequences and procedure of the
investigation or surgery in detail and a simple language before providing the protocol consent form to the
patient or to the responsible caretaker.
5. Right to confidentiality, human dignity and privacy: Now this one is a fairly known right. The code of
ethics dictates doctors to hold information about the illness and treatment plan for the patient in strict
confidentiality from everyone except the patient and their caretakers. In case of female patient, she has
the right to demand the presence of another woman if the medical worker checking/treating her is male.
6. Right to non-discrimination: Rights of a patient being upheld without discrimination based on their
illness, condition, HIV status or on their gender, age, religion, caste, ethnicity, sexual orientation, linguistic
or geographical or social origins.
7. Right to safety and quality care according to standards: Here is a brief list of provisions that come
under the list of quality care standards -
 Safety and security
 Cleanliness, infection control measures and sanitation facilities and safe drinking water
 Healthcare that abides by the latest standards, norms and guidelines under the NABH
 To be attended, treated and cared for in a professional manner (medical ethics)
 Right to seek red-ressal by patient or caretakers

8. Right to choose alternative treatment options if available: Hospital staff and doctors are responsible
for clarifying all treatment options to the patient/caretakers. They can choose a treatment option that
may/may not be a doctor’s recommendation.
9. Right to a second opinion: Doctors and the hospital must respect the patient/caretakers decision if
choose to seek a second opinion from a doctor/hospital of their choice. The hospital can neither stop nor
discourage patient/caretakers from going elsewhere. In case they choose to come back to the first
hospital after getting second opinion, the hospital still cannot compromise on the quality services.
10. Right to transparency in rates, and care according to prescribed rates wherever relevant: The patient
has the right to have a written account of the costs they will have to bear for the treatment.
11. Right to choose the source for obtaining medicines or tests: Patient has the right to choose pharmacy
they wish to buy medical supplies from. It also includes getting an investigation procedure (like a blood
test, for example) from any diagnostic centre or laboratory.
12. Right to proper referral and transfer, which is free from perverse commercial influences: If a patient
must be transferred from one healthcare centre to another, a proper and detailed justification must be
given to them/caretakers along with various options of the new healthcare centre. This step cannot be
taken unless the patient or their caretaker accepts it.
13. Right to protection for patients involved in clinical trials: According to the MoHFW, “All clinical trials
must be conducted in compliance with the protocols and Good Clinical Practice Guidelines’’.
14. Right to protection of participants involved in biomedical and health research: In case a patient is
involved in a biomedical or health research procedure, their consent needs to be taken in a written
format. Their right to dignity, privacy and confidentiality needs to be upheld during the research.
15. Right to be discharged, Right to receive the body of a deceased person from the hospital: A patient
has the right to be discharged and cannot be detained in a hospital, on procedural grounds such as [a]
dispute in payment of hospital charges. Similarly, caretakers have the right on the dead body and dead
body cannot be detained on non-payment or dispute in payment.
16. Right to Patient Education: The patient needs to be informed regarding; their health condition,
insurance schemes, how to seek red-ressal etc.
17. Right to be heard and seek red-ressal: Every patient has the right to address his grievances and give
feedback about the treatment they received. Patients/caregivers have the right to seek red-ressal in case
they are aggrieved, by lodging a complaint to an officials designated for this purpose in the hospital.

Legal issues in nursing

Most commonly occurring legal issues that impact on nursing and nursing practices are those that related
to informed consent and refusing treatment, licensure, the safeguarding of clients' personal possessions
and valuables, malpractice, negligence, mandatory reporting relating to gunshot wounds, abuse & unsafe
practices (like informed consent, documentation, staff and client education relating to legal issues), and
strict compliance with and adherence to all national, state, and local laws and regulations.

1. Licensure:
All nurses must be currently licensed to practice nursing in their respective state. Licensure protects the
consuming public and insures that the nurse has completed a state/central approved nursing program,
and has continuously met the requirement(s) for relicensure without any suspensions or revocations of
their license. Practicing without a current and valid license is illegal. Practicing nursing without a license is
crime, and subjected to Criminal Law.

2. Malpractice
Malpractice is an act of omission or commission that does not meet established standards of care and
causes some injury. Or, it is failure of nurse to meet the standards of acceptable nursing care that may
results in harm to the client. The common types of nursing malpractice are –
o Failure to report significant changes in a client's condition
o Failure to report defective equipment 
o Medication error / improper administration of medication
o Failure to follow physician’s order
o Doing or saying nothing when action is required
o Delaying patient care and/ or failure to monitor a patient
o Incorrectly performing a procedure or trying to perform procedure without training
o Documentation error
o Failure to get informed consent from patient
o Injuring patient with equipment
Action of omission and commission that lead to client injury place the nurses in jeopardy for malpractice
(unintentional tort under Civil Law). Nurses, therefore, must provide all aspects of nursing care according
to established standards of care, in a safe and competent manner, and also done in a complete,
appropriate and timely sense. However, some Do’s and don’ts ensure the nurses for safe practice –
 Do get current license to practice nursing in the respective state
 Do document all unusual incidences
 Do report all unusual incidences
 Do document all nursing care factually and thoroughly reflects nursing process
 Do follow policies and procedures as established by the health care agency
 Do protect the patient from injury
 Do not advice anything that is contrary to the doctors order or nursing care services
Who Is Responsible for Nursing Malpractice?
Often, a key issue in nursing malpractice cases revolves around who is responsible for the nurse's
Negligent Acts; the Hospital or an Attending doctor or the Nurse itself?
The Hospital may be legally and financially responsible for nursing malpractice if; (1) the nurse was an
employee of the hospital, (2) the nurse was fulfilling a job duty when the patient was injured, and (3) an
independent Doctor (that is, one not employed by the hospital) was not in control of the Nurse.
As most of the nurses serves as employees in India, the hospitals are frequently a defendant in nursing
malpractice cases.
If an attending doctor is supervising the nurse, the hospital may be off the hook even though it is the
nurse's employer. Whether the nurse is under the supervision of the doctor when the misdeed occurs
depends on; (1) whether the doctor was present, and (2) whether the doctor had control to prevent the
nurse's negligence.
The issue of whether or not the doctor could control the nurse at the time of the negligence is normally a
dispute between the doctor and the hospital -- the outcome does not change whether an injured patient
can recover for malpractice, it just determines who pays.
Even if the doctor supervised the nurse, the hospital still might be liable if the doctor gave improper
orders and the nurse should have known they were improper but followed them anyway.

3. Negligence
Negligence is also an act of omission or commission that does not meet established standards of care.
Negligence differs from malpractice, because it lacks one or more of the six elements of malpractice that
are essential to be considered as malpractice. However, following are some examples of negligence -
o Failure to follow standards of care
o Failure to use equipments in a responsible manner / improper use of equipments
o Failure to assess, monitor and failure to communicate
o Failure to document
o Failure to act as a patient advocate
Actions of omission and commission that lead to client injury place the nurse in jeopardy for negligence
(un-intentional tort under Civil Law). Nurses, therefore, must very cautious in providing all aspects of
nursing care according to established standards of care, in a safe and competent manner.

4. The Safeguarding of Clients' Personal Possessions and Valuables

Nurses are responsible for safeguarding and respecting the clients' personal possessions and valuables;
they must also not, under any circumstances, borrow or steal their personal possessions and valuables.
Although policies and procedures relating to the safeguarding of clients' personal possessions and
valuables may vary from one healthcare facility to another, these policies typically include discouraging
clients to retain personal items while hospitalized, and then securing the retained personal belongings
(lockers /or secure & safe envelope) until discharge.

5. Invasion of Privacy
Invasion of privacy is the intrusion into the personal life of another, without just cause. In the routine
course of client care, absolute privacy is invaded, but this type of invasion is deemed acceptable by the
courts. Negligent disregard for right to privacy, particularly when the patient is unable to protect himself,
such as in the case of unconsciousness or immobility, is legally actionable.
The right to privacy is recognized by the law as the right to simply be left alone. It is the right to be free
from unwarranted publicity and exposure to public view, as well as the right to live one's life without
having one's name, picture, or private affairs made public against one's will. Hospitals, physicians and
nurses may become liable for invasion of privacy if they divulge information from a medical record to
improper sources.
6. Disclosure of Information
Disclosure of Information is somewhat similar to invasion of privacy. It occurs when a client's problems
are inappropriately discussed with any third party. Information given to nurses by clients is often very
personal and detailed. The client's bill of rights states that the client has the right to expect confidentiality
in the health care relationship.
7. Defamation of Character
Defamation of character is an act of communication that causes someone to be shamed, ridiculed, held in
contempt, lowered in the estimation of the community, or to lose employment status or earnings or
otherwise suffer a damaged reputation. Such defamation is couched in 'defamatory language'.   The ‘’Libel
and slander’’ are subcategories of defamation. There are four generally recognized exceptions where no
proof of actual harm to reputation is required in order to recover damages:
 Accusing someone of a crime
 Accusing someone of having a horrible disease
 Using words which affect a person's profession or business
 Calling a woman unchaste
8. Infliction of Mental / Emotional Distress
Intentional infliction of emotional or mental distress is a tort claim for intentional conduct that results in a
mental reaction. This includes imposing mental suffering resulting from painful emotions, such as grief,
public humiliation, despair, shame, wounded pride, etc. Liability for the wrongful infliction of mental
distress may be based upon either intentional or negligent misconduct.
One of the major hurdles in an intentional infliction of emotional distress lawsuit is proving that the
defendant's conduct was extreme or outrageous. Generally, it should be so outrageous in character, and
so extreme in degree, as to go beyond all possible bounds of decency, and to be regarded as atrocious,
and utterly intolerable in a civilized community.
9. Mandatory Reporting
Nurses are legally mandated to report abuse, neglect, gunshot wounds, dog bites, some communicable
diseases and any unsafe and/or illegal practices done by another health care provider.
10. Documentation
All documentation and all forms of documentation are considered legal documents. Some of the legal
aspects of documentation, in addition to the legal mandates associated with confidentiality, include the
strict legal prohibitions against altering a record, obliterating entries in the medical record, and falsifying
documentation.
Other guidelines for documentation include the use of permanent ink, the use of only accepted terms and
abbreviations, legible writing, accurate spelling, proper grammar, accurate dating and time of the entry,
the signature and title of the person who documented the entry, and a professional tone.
11. Acceptance of an Assignment
Nurse are legally accountable to accept only those assignments that are appropriate in terms of their
nurse practice act and their scope of practice, and only those that the nurse believes that they are
competent to perform.
12. Compliance with and adherence to Other Laws
Nurses are also expected to comply and adhere to national, state, and local laws and regulations. For
example, the compliance with the Centers for Medicare and Medicaid Services must be adhered to, state
laws relating to professional licensure and mandatory reporting must be complied with, and local laws
relating to the disposal of bio-hazardous waste must also be followed without fail.

Legal safeguards in nursing / precautions in nursing practice / legal

responsibilities of professional nurses

1. Nurses must be currently licensed to practice nursing in the respective state. Be aware of ‘’Nurse
Practice Act’’, and review them on a regular basis. This general knowledge on Laws applicable to
nursing profession ensures safe practice in nursing service / administration.
2. Nurses must be aware of ‘’Bill of Rights for Registered Nurses’’ at their workplace.
3. Nurses must be well aware of Service Rules & Regulations of their health care agency, and review it
regularly for any changes in the policies. Strictly adhere to an employer’s adopted policies and
procedures.
4. If the nurse is an Advanced Nurse Practitioner; order medication, treatment and other healthcare
regimen within the scope of nursing practice.
5. Be clinically competent in chosen specialty. Participate in research or and carry out research study
that can reduce liability when providing care to patients.
6. Be an active consumer of nursing research.
7. Participate in CNE programs to maintain continued competency in the areas the nurse practice.
8. Move on to ICE i.e., enroll in an Advanced Nursing Program (viz., higher education, post diploma
nursing programs, or certificate courses) to increase an ability to use critical thinking and problem
solving skills in nursing practice.
9. Nurses must focus on and use EBP
10. Maintain direct and honest communication with nursing and other healthcare team members,
patients and patients’ families.
11. Utilize a risk management approach when providing care to patients to decrease risk of injury to or
death of a patient.
12. Know your protections under workers’ compensation laws and report any injury in the workplace as
required under the law.
13. If you’re a union member, evaluate your benefits and rights and use the bargaining agreement’s
protections, as needed.
14. Uphold safety requirements in the workplace for yourself and patients.
15. Adhere to your facility’s chain of command when reporting patient care issues.
16. Develop good rapport with the client that may help in prevention of malpractice and negligence.
17. Obtain ‘’informed consent’’ from the patient / relatives before any sort of diagnostic procedure,
surgery / operation etc.
18. Count the sponge, needles and instruments for all surgical procedures that take place in OT.
19. Minimize risk of medication error by using ‘5R’s while administering any type medications.
20. The ‘’dangerous / poisonous drug record’’ should be kept and maintained properly. Further, the nurse
must be aware of ‘’Misuse of Drug Act’’ and ‘’Dangerous of Drug Act’’ that control the use of poisons
in medicine.
21. Follow job descriptions, policies, rules & regulations, and ANA Standards of Nursing Practice that
helps to safeguard from malpractice and negligence.
22. Practice ethics that uphold the INC Code of Conduct for Nurses.

23. Do document and Report all unusual incidences.

24. Promptly file the incidence reports for any deviation in nursing care. Report abnormal assessment
including, lab findings, follow-ups etc. for safe nursing practice.
25. Do keep necessary records accurately as it is legal responsibility of nurse
26. Avoid using bullying, intimidating or other behaviors that are not respectful of patients or fellow staff.
27. Use ‘’Standing Orders’’ appropriately & carefully, and record the action immediately.
28. Be a ‘Good Samaritan’; many states have enacted ‘’Good Samaritan Laws’’ that exempt doctors and
nurse from liability when they render first aid during emergency.
29. Join and become an active member of professional nursing associations that affect your specific
practice.

Ethical Aspects in Nursing

Every day, patients, families and healthcare professionals including nurses face ethical and legal decisions.
These difficult dilemmas may concern medical treatments, practices, hospital management and other
matters that arise in the healthcare industry. Ethical issues in healthcare can require an immediate
response, such as making decisions for patients when they are not able to do so, or can involve a
prolonged, carefully considered decision, such as the debate over the right to abortion or assisted suicide.
The actions taken in ethical issues in healthcare clearly distinguish between what is right and wrong, and
often, many of the actions taken today can have lasting effects on healthcare in the future.
What is Ethics?
Ethics are moral principles that are concerned with the good of individuals and the good of society. Ethics
govern our rights and responsibilities and guide moral decision-making. Throughout the centuries,
philosophies, religions and cultures have shaped ethics so that, throughout the world, different peoples
may hold different beliefs. Professional organizations, such as those governing health care providers, have
established ethical guidelines for all practitioners, regardless of their personal beliefs.
Ethics is a branch of philosophy dealing with values pertaining to human conduct, considering the
rightness or wrongness of actions, and the goodness or badness of the motives and ends of such actions.
In other words, it is a systematic rules or principles governing right conduct.
What is Nursing Ethics?
Nursing Ethics is the values and ethical principle governing nursing practice, conduct and relationships. In
other words, it is a system of principles governing the conduct of nurse.
Nursing ethics deals with the relationship of a nurse to the patient, the patient’s family, associates and
fellow nurses, and society at large.

Why a Code of Ethics Necessary?

A code of ethics takes the emotion out of decision-making. Health care providers often see patients and
their families in difficult situations. Witnessing the pain of others is difficult. There can be the temptation
to "go with one's gut" and make a care decision based on a feeling rather than on experience, training and
a professional code of conduct. When it comes to patient care, decisions are not always black and white.
There can be a lot of gray areas. A code of ethics helps nurses navigate those gray areas to provide safe
and competent care to their patients.

INC Code of Ethics for Nurses in India

I. Nurse respects the uniqueness of individual in provision of care
a. Provides care for individuals without consideration of caste, creed, religion, culture, ethnicity,
gender, socio-economic and political status, personal attributes, or any other grounds
b. Individualizes the care considering the beliefs, values and cultural sensitivities.
c. Appreciates the place of the individual in family and community and facilitates participation of
significant others in the care.
d. Develops and promotes trustful relationship with individual (s).
e. Recognizes uniqueness of response of individuals to interventions and adapts accordingly.
f. Appreciates the place of the individual in family and community and facilitates participation of
significant others in the care.
2. The nurse respects the rights of individuals as partner in care and helps in making informed choices
a. Appreciates individual’s right to make decisions about their care and therefore gives adequate and
accurate information for enabling them to make informed choices.
b. Respects the decisions made by individual (s) regarding their care.
c. Protects public from misinformation and misinterpretations.
d. Advocates special provisions to protect vulnerable individuals/groups.
3. Nurse Respects individual’s right to privacy, maintains confidentiality, & shares information judiciously
a. Respects the individual’s right to privacy of their personal information. Maintains confidentiality
except in life threatening situations and uses discretion in sharing information.
4. Nurse maintains competence in order to render Quality Nursing Care
a. Nursing care must be provided only by registered nurse.
b. Nurse strives to maintain quality nursing care and upholds the standards of care.
c. Nurse values continuing education, initiates and utilizes all opportunities for self development.
d. Nurse values the research as a means of development of nursing profession, and participates in
nursing research adhering to ethical principles.
5. Nurse is obliged to practice within the framework of ethical, professional and legal boundaries
a. Adheres to code of ethics and code of professional conduct for nurses in India developed by INC.
b. Familiarizes with relevant laws and practices in accordance with the law of the state.
6. Nurse is obliged to work harmoniously with the members of the health team
a. Appreciates the team efforts in rendering care.
b. Cooperates, coordinates & collaborates with health team members to meet the needs of people.
7. Nurse commits to reciprocate the trust invested in nursing profession by society
a. Demonstrates personal etiquettes in all dealings.
b. Demonstrates professional attributes in all dealings.

Principle of Nursing Ethics

There are certain ethical principles that arise frequently for the nurse while working. And these principles
serve as a guide to the nurse in making ethical decisions. The registered nurse can find support for ethical
decisions by referring to the INC code of ethics.

1. Respect for persons: (each person has the capacity and right to make their own decisions). Respect
for persons is the concept that all people deserve the right to fully exercise their autonomy.
Showing respect for persons is a system for interaction in which one entity ensures that another
has agency to be able to make a choice. This concept is usually discussed in the context of
research ethics.

2. Autonomy (principle of human dignity): Autonomy is delivered from Latin word "self-rule". It as an
individual's capacity for self-determination or self-governance. In other words, it is the
independence of one’s thoughts and actions. Nurses have an obligation to honor/respect
the autonomy of patients; i.e., respect the decisions made by them on their own behalf. Nurses
must allow the patients to make decisions and respect their right’s to accept/reject any treatment.

3. Beneficence (doing good): is defined as an act of charity, mercy, and kindness with a strong
connotation of doing Good to others including moral obligation. Beneficence is an Ethical
Principle that addresses the idea that a nurse's actions should promote good. Doing good is
thought of as doing what is best for the patient. Nursing beneficence takes on many different
forms. Examples: Resuscitating a drowning victim (CPR). Providing pain medication as soon as
possible to an injured patient in the emergency room. Lifting side rails on a patient's hospital bed
to prevent falls.

4. Non-maleficence (avoiding harm): This principle requires an intention to avoid needless harm or

injury that can arise through acts of commission or omission. In other words, the principle of non-
maleficence holds that there is an obligation not to inflict harm on others.
 Example, let's image an elderly man with terminal cancer does not want resuscitation and notifies
his nurse of that choice. He has a cardiac pain and the nurse wants to attach him to a ventilator.
The nurse's action will only prolong his dying, and nurse is guilty of maleficence, since the actions
provide no benefit or good effect but do inflict intentional harm.

5. Justice (fairness, equitability, truthfulness) : This principle states that there should be an element of
fairness in all medical decisions i.e., equal distribution of resources, equality in treatments, and for
medical practitioners to uphold applicable laws and legislation when making choices.
The right to be treated equally can be found in many constitutions. But in actual practice, a
number of different factors may influence actual access to treatment (or unfair treatment) e.g.
age, place of residence, social status, ethnic background, culture, sexual preferences, disability,
legal capacity, hospital budgets, insurance cover and prognosis. 

6. Veracity (truthtellling): It refers that the nurses should deal with the patients honestly. It is the
basis for trust relationship between the patient and nurse.
Veracity in nursing is not simple black & white since there is no clear line between when lying is
acceptable and when not. In many circumstance, nurses are faced with moral and ethical
decision. A good example of an actual/white lie is when a nurse tell a patient/or their relatives that
everything going to be fine (withholding the truth) when she know that he will probably not
survive the night.

7. Fidelity (remaining faithful to one’s commitment) : Refers that nurses must be faithful to the
promises they made as professionals to provide competent, quality care to their patients. In
nursing, fidelity is the most important of the ethical principles because it governs the other six.
Fidelity is common source of ethical conflict in nursing. Nurses may find themselves caught
between what they believe is right, what the patient wants, what others expect, and what is
required by organizational policy and the law. Fidelity requires that nurses treat all patients with
respect. It's not always easy, especially if a patient is disagreeable, uncooperative or rude. Nurses
need to put aside any negative feelings they might have about such patients and adhere to the
standard of care. Nurses should talk with their team members if they believe their feelings toward
a patient could compromise care.

Ethical issues in nursing

There are numerous ethical challenges the professional nurses and patients face in healthcare. Some
examples of common nursing ethical issues include -
1. Patient privacy and confidentiality: The protection of private patient information is one of the most
important ethico-legal issues for nurses. Conversations between a physician/nurses and a patient are
strictly confidential, as is information about an individual’s medical condition.
2. Transmission of diseases: The recent global outbreak of the Ebola virus / Corona virus (COVID-19) put a
renewed emphasis on the right of healthcare providers to protect themselves from communicable
diseases, whether by direct or indirect contact with an infected patient. Ethical and legal questions arise
when a patient’s health history is not provided to the medical staff.
3. Relationships: Sexual relationships between medical practitioners and patients or between medical
staff are strictly forbidden at a healthcare facility. Sexual harassment can be harmful to all involved,
including the facility, so the code of ethics should be explicit about this.
4. End-of-Life issues: End-of life care is another ethical concern for the correctional nurse. Terminally ill
patients may have specific wishes about the way they want their lives to end. Families may struggle with
the decision to end life support for a loved one. Healthcare practitioners and clinical leaders need to be
prepared to handle end-of-life issues as well as problems encountered in dealing with elderly patients
who may not be able to make rational decisions on their own.
5. Honesty vs. Withholding information: Family members may want to withhold medical information
from the sick to protect their emotions. However, patients have the right to know about their medical
conditions. Deciding how to share this information, especially if it goes against the family’s beliefs, can be
a touchy situation. The ANA advocates for truthtellling, or veracity, as a key factor in nurse-patient
relationships.
6. Science vs. Spirituality: Healthcare, which is science-based and results-driven, can impede on religious
or personal beliefs. Some religions restrict medical interventions and lifesaving techniques. Nurses focus
on providing medical care to reduce suffering, and to allow patients to concentrate on self care. For
patients or their families with strong religious or spiritual convictions, the focus may be on adhering to a
strict set of guidelines.
7. Healthcare needs vs. Resource allocation: The rising cost of healthcare is increasingly putting nurse
managers at odds with budgeting constraints and patient needs. A large number of medical facilities have
scarce resources which puts patients at risk for not getting the care they need. These resources range
from medical equipment to healthcare staff. Research suggests nurse leaders must include staff in the
budgeting process so they can better understand the needs and demands.
8. Autonomy vs. Beneficence: Nurses are required to administer prescribed medicine, but patients, at the
same time, can refuse them. Patient autonomy can go against medical directives, despite clearly defined
needs. Patients have a right to refuse all medical care. Hence, it is essential to use ethical principles to
arrive at a solution in an atmosphere of caring, respect, openness, and honesty.
9. Non-maleficence: Nurses are obligated not to harm patients; on the other hand, they have to perform
procedures that make patients’ feel uncomfortable (e.g., IM injection to relieve a symptom). The nurse
may cause discomfort/harm due to therapeutic procedure. Hence, non-maleficence must be balanced by
beneficence, while providing care.
10. Informed consent: common ethical issue arises when the patient and their families have not been
fully informed about their treatments or clinical prognosis, and can create great concern for nurses.
Patients feel more comfortable asking the nurse to explain what was said by the doctor. But it’s an ethical
issue about how much they should convey. 
11. Cultural diversity and nursing care: Cultural diversity and caring for people with different values and
traditions, and accepting their rituals, can present ethical challenges to the nursing practice setting.
Effective communication and education can help address this type of ethical scenario.
12. Communication and workplace: Nurses report communication difficulties and workplace bullying and
violence as serious work environment ethical dilemmas. The hierarchy or work structure does not
encourage conversations. Committee meetings to be organized to allow such discussions to take place
where everyone can comfortably speaking up.
13. Patient safety and staffing: Patient safety and staffing issues also fall into the work environment
category that is again an ethical issue. Nurses frequently report that just they do not have time to do what
they intended for patients; helping them recover or adapt, or addressing patients’ emotional needs.
14. Disclosing the medical conditions: For example; an older adult is admitted to a hospital with terminal
cancer. The doctors believe he has just a few months to live. And, the family believes it's best for the
patient to maintain his positive attitude; so, they ask the nurse not to tell him the whole truth about his
condition. The nurse has an obligation to the patient's right to know and the ethical principle of non-
maleficence and fidelity – the obligation to prevent harm and the obligation to be faithful to colleagues.
The nurse’s own value of truthtellling must also be considered.
15. Noncompliant patients: Ethical dilemmas for emergency room nurses sometimes stem from patients
brought into the ER who clearly require acute medical care but aggressively decline medical treatment.
While a patient has the right to be autonomous, for a nurse, it as an ethical obligation to advocate for
needed medical treatment. In spite of that (unfortunately), nurses may try to administer care and
dispense prescribed medications, but the patient has every right to refuse all medical treatment, even if it
means they may not survive. Nursing ethics require informing patients about necessity of medical
treatment, but can’t force them to accept it. 

16. Anti-vaccine dilemmas: Ethical concerns about autonomy versus beneficence often become a heated
debate when addressing childhood immunizations. A parent’s autonomy gives them the right to refuse to
immunize their children, but not vaccinating potentially poses a public health hazard and could cause
previously eradicated diseases to reappear.  
17. Allowing Personal beliefs to interfere with patient care: Personal beliefs can also affect how nurses
approach to patient education. It can be challenging when a nurse does not believe in specific treatments
like vaccines, medications, or invasive surgeries or procedures. While it's perfectly acceptable to hold
certain beliefs; but the nurses should present actual facts, and should educate patients on ‘’what the
treatment does’’, and not ‘’what they believe’’.
18. Religion and health care: Some religious beliefs strictly prohibit the use of specific branches of
modern treatment. Those who are practicing these religions might report to an emergency room or
hospital in need of a blood transfusion, but deny the procedure based on their religious beliefs.
A nurse might attempt to appeal the logical side of patient / family by discussing the life-or-death nature
of a procedure, but religious beliefs often win the battle.
19. Unethical Leadership: Having a personal issue with higher authority is one thing, but reporting to a
person who is behaving unethically is another issue in many health care agencies. However, it can also
occur more subtly, in the form of bullying, accepting bribes, or asking you to skip a standard
procedure just once etc. 
20. Toxic workplace culture: some of the health care organizations helmed by unethical leadership with a
toxic workplace culture. For example; profit-minded leadership, autocratic leadership, manipulating
policies/service rules, favoritism (in terms of gender, caste, place), pressuring employees or subordinates
for favors, socio-cultural discrimination, gender discrimination, disrespecting and bullying the employees,
physical/sexual harassment, mental harassment etc. These kinds of toxic culture may result not only an
ethical issues but also a legal ramifications.

How to handle or deal with the ethical issues in nursing

No matter what type of ethical issues nurses are facing; remember there are avenues for assistance,
including nurse managers or ethics committee. However, following are some clues to deal with issues -
 The nurses must always ask themselves, 'What are the goals of the patient and/or family?' Our
role is to help the patient and family meets those goals, not convince them otherwise.  
 They must also ask themselves, 'the treatment I'm concerned about will meet the goals of the
patient and/or family?' If the answer is yes, then the treatment should be continued; if not, the
treatment shouldn’t be done.” 
 The ethical concerns may change as the nurse matures in his or her role; hence, consult the senior
nurse professionals for the solution of ethical dilemma.

 Every hospital should have an ethics committee and nurses need to have a voice in the decisions
that are being made. They can access an ethics committee to voice their concerns and get help.

 Hospitals are increasingly using patient simulation as a learning tool. Nurse can use high-fidelity
patient simulation (HPS) in the form of computerized mannequins to learn advanced skills. They
help nurses develop clinical judgment. Nurses get practice in the kinds of decision-making they will
be called upon to perform in their professional lives.
 The nurses should undergo “Ongoing education in ethics”. To deal with ethical conflicts, the nurse
should typically take additional coaching in life sciences, social sciences and the humanities. They
also should attend CNE like seminar, workshop, conference etc.

Decision making in ethical dilemma

1. The nurse should identify and define the ethical issue
2. Find for possible options / course of action after discussing with patients/caretakers
3. Who should make the choice (patient alone or patients/caretakers or nurses)
4. Outline options (consequences; merits/de-merits or good/bad)
5. Resolve the dilemma (in consultation with senior nurse/ward in-charges/Nsg. Supt.
6. Desired outcomes / look back and evaluate the entire process