Ethical problems in healthcare are easy to associate with exceptional situations such as withdrawal of life-sustaining treatment, decision-making capacity, organ allocation, or refusal of treatment. Many consequential ethical questions also arise during routine care, especially when familiar practices affect patient autonomy, safety, fairness, or the ability of clinicians to raise concerns.
They may appear when a workaround becomes routine, when barriers to completing a care plan are interpreted as patient nonadherence, or when hierarchy makes speaking up difficult. The 2025 American Nurses Association Code of Ethics for Nurses describes ethical responsibility across relationships with patients, colleagues, the profession, society, and the environments in which nursing care occurs (American Nurses Association [ANA], 2025). AACN likewise incorporates ethics throughout professional nursing education and identifies autonomy, beneficence, nonmaleficence, justice, moral distress, moral community, and moral resilience among concepts relevant to professional nursing practice (American Association of Colleges of Nursing [AACN], 2026).
Ethical Principles Help Define the Conflict
Autonomy, beneficence, nonmaleficence, and justice provide a useful framework for examining ethical problems. AACN (2026) describes autonomy in relation to self-determination, beneficence as promoting good, nonmaleficence as avoiding or minimizing harm, and justice as fairness in the distribution of benefits, risks, and burdens.
Clinical situations become more difficult when these obligations point in different directions. A patient may refuse a treatment clinicians believe offers substantial benefit. An intervention may prolong life while also increasing treatment burden. A discharge plan may satisfy clinical criteria while leaving unresolved barriers to medication access or follow-up. Identifying the competing ethical principles helps clarify whose interests are affected, where obligations conflict, and what additional information is needed to evaluate the available choices.
Ethical analysis does not necessarily produce one obvious answer. Its value lies in making the competing obligations visible enough to examine rather than allowing habit, convenience, or hierarchy to determine the outcome without scrutiny.
Ethical Problems Can Become Normalized
Routine practices deserve periodic ethical examination because familiarity does not establish that a process remains appropriate. A workaround created for an unusual circumstance may gradually become common. A process that repeatedly creates difficulty for patients may continue because staff have learned how to compensate for it. Unprofessional communication may become tolerated when colleagues adapt to the behavior instead of addressing the environment that allows it to persist.
ANA Provision 6 places responsibility on nurses, individually and collectively, to establish, maintain, and improve an ethical work environment that supports safe and quality care (ANA, 2025). That responsibility extends beyond responding to obvious ethical violations. It also requires attention to whether ordinary practices continue to support dignity, safety, fairness, and professional integrity.
Useful questions include whether a process still has a defensible clinical or operational rationale, whether it creates predictable burdens for particular patients or staff, whether concerns can be raised safely, and whether the original reason for a workaround still exists. Examining familiar practices through an ethical lens can reveal problems that have become difficult to notice precisely because the organization has adapted to them.
Moral Distress and Psychological Safety Affect Speaking Up
Moral distress is a longstanding concept in nursing ethics, although its definition has evolved and remains debated. Jameton’s early formulation focused on situations in which clinicians believe they know the ethically appropriate action but experience constraints that interfere with carrying it out. Later scholarship has broadened and critically examined the concept, including whether moral distress should encompass a wider range of morally troubling experiences (Jameton, 2013; Morley et al., 2019). AACN includes moral distress among the ethical concepts relevant to professional nursing education (AACN, 2026).
Clinical environments can intensify these experiences when clinicians perceive a conflict between appropriate care and the constraints surrounding their ability to act. In critical care, for example, nurses may spend prolonged periods at the bedside during disagreement or uncertainty about goals of care while having limited authority over some treatment decisions. The ethical concern may involve the treatment itself, communication with the patient or family, organizational constraints, or the clinician’s perceived inability to influence the course of care.
Moral courage becomes relevant when acting on an ethical concern carries interpersonal or professional risk. Dehghan Nayeri et al. (2025) found a strong positive association between moral courage and patient safety culture among nurses working in COVID-19 and non-COVID-19 settings. Because the study was cross-sectional, the findings support an association and do not establish that moral courage causes improvements in safety culture.
Psychological safety also influences whether clinicians feel able to raise questions or concerns. Cho et al. (2023) found that greater psychological safety among hospital nurses was associated with greater communication openness, higher job satisfaction, lower intention to leave, and more favorable nurse-reported patient safety ratings. These findings support examining the environment surrounding ethical action in addition to the characteristics of the individual clinician.
ANA’s ethical framework reinforces this organizational dimension by placing responsibility on nurses collectively as well as individually to support an ethical work environment (ANA, 2025). When routine questions or safety concerns consistently carry substantial interpersonal risk, the ethical environment itself deserves examination.
Autonomy and Justice Depend on Meaningful Access
Respect for autonomy requires meaningful participation in healthcare decisions. Patients need understandable information and an opportunity to consider how available options fit their values, circumstances, and priorities. AACN’s ethical and person-centered care competencies emphasize self-determination, individual values, contextual factors, and participation in care decisions (AACN, 2026).
The existence of a healthcare option does not always mean a patient can realistically use it. Follow-up may be difficult without transportation, a medication may be financially inaccessible, or telehealth may be impractical without reliable technology or privacy. These examples do not establish that every barrier creates an ethical violation, but they can affect whether a patient’s available choices are as meaningful in practice as they appear on paper.
Justice adds attention to how opportunities, risks, and burdens are distributed (AACN, 2026). When the same process repeatedly creates greater difficulty for patients with fewer resources, ethical analysis should consider whether the structure of care is contributing to that burden instead of attributing every unsuccessful outcome to individual motivation or behavior.
Beneficence also requires attention to the patient’s definition of benefit. Clinical expertise informs recommendations, while patients may reasonably place different weight on symptom control, independence, treatment burden, employment, caregiving responsibilities, or avoidance of hospitalization. Person-centered ethical care incorporates those values into decision-making while maintaining clinically responsible recommendations (AACN, 2026).
Accountability Exists at Both Individual and System Levels
Individual clinicians remain accountable for competent practice, accurate communication and documentation, appropriate escalation, and decisions within their professional role. Organizational context does not remove that responsibility. At the same time, ANA Provision 6 explicitly extends ethical responsibility to the environment of practice and calls on nurses, individually and collectively, to establish, maintain, and improve conditions that support ethical nursing care (ANA, 2025).
This distinction becomes important when the same problem occurs repeatedly. If staff routinely bypass a required workflow, the individual behavior deserves attention, but the feasibility and safety of the workflow may also require review. If clinicians hesitate to report concerns because previous reporting has been met with humiliation or retaliation, examining individual speaking-up behavior without examining organizational culture provides an incomplete explanation.
Recurring concerns involving discharge processes, medication safety, communication, access, or goals of care may indicate that part of the problem resides in policy, workflow, resources, education, or organizational culture. Repetition does not prove that the system is responsible, but it creates a reason to investigate whether the conditions surrounding individual decisions are contributing to the pattern.
A systems perspective therefore complements individual accountability. Ethical analysis becomes more complete when it considers what responsibility belongs to the clinician and what responsibility belongs to the team or organization capable of changing the environment in which care occurs.
Ethics Is Hardest to See After a Problem Becomes Ordinary
Ethics education provides a framework for reconsidering practices that have become familiar. Autonomy deserves attention before a patient’s choices become severely constrained. Workarounds deserve scrutiny before harm exposes weaknesses in the process. Psychological safety deserves attention before silence becomes an expected response to concerns.
A healthcare service does not become equitable solely because every patient is technically eligible to use it, and an ethical workplace requires more than the existence of policies or reporting mechanisms. Ethical nursing practice requires continued attention to clinical decisions, professional relationships, organizational culture, access, and the systems that influence what healthcare professionals come to accept as routine. Some of the most consequential ethical problems may be difficult to recognize because familiarity has made them appear ordinary.
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References
American Association of Colleges of Nursing. (2026). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2026.pdf
American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/
Cho, H., Steege, L. M., & Arsenault Knudsen, É. N. (2023). Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses. Research in Nursing & Health, 46(4), 445–453. https://doi.org/10.1002/nur.22327
Dehghan Nayeri, N., Shahmari, M., Shifteh, S., Rasouli, K., Ranjbar, A., & Zare, L. (2025). Moral courage as a predictor of patient safety: Reflections from the COVID-19 era. BMC Health Services Research, 25, Article 1077. https://doi.org/10.1186/s12913-025-13310-7
Jameton, A. (2013). A reflection on moral distress in nursing together with a current application of the concept. Journal of Bioethical Inquiry, 10(3), 297–308. https://doi.org/10.1007/s11673-013-9466-3
Morley, G., Ives, J., Bradbury-Jones, C., & Irvine, F. (2019). What is “moral distress”? A narrative synthesis of the literature. Nursing Ethics, 26(3), 646–662. https://doi.org/10.1177/0969733017724354