Before We Start
Why ethics matters in daily nursing practice
Ethical dilemmas in nursing are not rare, dramatic events. They happen every shift — when a patient refuses a medication their family insists they need, when a colleague cuts corners on documentation, when a family demands aggressive treatment for a patient who has a DNR order.
The ethical principles of nursing give you a framework for thinking through these situations — not a script for every scenario, but a set of values that guide you toward the right decision when the situation is unclear.
On NCLEX, ethical questions test whether you can identify the correct principle in a given situation and understand what it requires of the nurse.
The Five Principles
BAJF + Non-maleficence — each principle explained
B — Beneficence
Do good — act in the patient's best interest
Beneficence means actively doing good — taking positive action to benefit the patient. It is the nurse's duty to promote the patient's health and well-being, prevent harm, and remove existing harm.
Nursing examples:
• Administering pain medication to relieve suffering
• Advocating for a patient who cannot advocate for themselves
• Educating a patient about their condition so they can make informed decisions
• Monitoring for and preventing complications
Conflict with autonomy: Beneficence sometimes conflicts with what the patient wants. A patient may refuse a medication that you know will help them. In most cases, autonomy wins — but beneficence requires you to ensure the patient has been fully informed before refusing.
💊 Beneficence = "what is best for this patient?" — the nurse's duty to actively promote the patient's health and welfare through every action.
A — Autonomy
The patient's right to make their own decisions — even bad ones
Autonomy is the patient's right to self-determination — to make informed decisions about their own body and healthcare, free from coercion.
What autonomy requires of the nurse:
• Informed consent — patient must be fully informed before consenting to any procedure
• Right to refuse — a competent patient can refuse any treatment, even life-saving treatment
• Advance directives — patient's wishes documented in advance (DNR, living will, healthcare proxy)
• Cultural and religious beliefs — must be respected even when they conflict with medical recommendations
Example: A Jehovah's Witness who refuses a blood transfusion that could save their life must have that refusal respected. The nurse may disagree. The nurse may educate the patient about the risks of refusal. But if the competent patient refuses — that decision is honored.
💊 Autonomy wins over beneficence in most situations. A competent patient's informed refusal overrides what the nurse or doctor believes is best — always document the refusal and the education provided.
J — Justice
Fair and equal treatment for all patients
Justice in nursing means treating all patients fairly and equitably — distributing resources based on need, not on personal characteristics, and advocating for equal access to care.
Justice requires:
• Providing the same quality of care regardless of race, religion, socioeconomic status, gender, sexual orientation, or any other characteristic
• Fair allocation of scarce resources (ICU beds, ventilators, organ transplants)
• Advocacy for underserved populations
• Reporting unsafe practices that create unequal care
Justice in resource allocation: When resources are limited, allocation decisions must be based on medical need and potential benefit — not on social worth, ability to pay, or personal preference of the care team.
💊 Justice = the same nurse you are for your most likable patient is the nurse you must be for your most difficult one. Every patient deserves your best care.
F — Fidelity
Keep your promises — follow through on commitments
Fidelity is faithfulness — keeping promises and honoring commitments made to patients. It is the foundation of the trust relationship between nurse and patient.
What fidelity looks like:
• "I'll be back to check on your pain in 30 minutes" — then actually coming back
• Following through on care that was promised
• Maintaining confidentiality (which is also a fidelity obligation)
• Being honest — even when the truth is difficult
Veracity (closely related to fidelity): The obligation to tell the truth. Nurses must communicate honestly — about medications, procedures, diagnoses, and prognosis. Withholding important information from a patient without their consent is a violation of veracity.
💊 "I'll come back in 30 minutes" is a promise. If you don't come back — you've violated fidelity and destroyed trust. Either come back or tell the patient you can't.
Non-maleficence
First, do no harm — the oldest principle in medicine
Non-maleficence means avoiding actions that cause harm to the patient. It is the companion to beneficence — while beneficence means doing good, non-maleficence means not doing harm.
Examples in nursing:
• Not administering a medication you know is wrong (wrong dose, wrong patient, known allergy)
• Reporting a colleague who is practicing unsafely
• Refusing to perform a procedure you don't feel competent to do
• Weighing the potential harm of an intervention against its benefit
Balancing beneficence and non-maleficence: Almost all medical treatments involve some risk of harm alongside potential benefit. The ethical question is whether the potential benefit outweighs the potential harm — and whether the patient has been informed of both.
💊 If you know a medication dose is wrong — do not give it. Non-maleficence requires you to prevent harm even when ordered to act. Clarify first. Always.
🏥 Ethical Dilemma Scenarios — Applying the Principles
Three scenarios. Identify the ethical principle at stake and the correct nursing action.
1
Scenario: A 78-year-old patient with terminal cancer has a DNR order. During your shift he becomes unresponsive. His adult daughter arrives and demands you "do everything."
Principle: Autonomy — the patient's documented advance directive represents his autonomous decision about his own care.
Correct action: Honor the DNR. Comfort care only. Notify the physician. Support the family emotionally. Explain that the DNR represents the patient's own wishes, which must be respected. Document thoroughly.
2
Scenario: A patient refuses a recommended blood transfusion for a hemoglobin of 6.2. She is alert, oriented, and understands the risks of refusal. Her reason is religious.
Principle: Autonomy — a competent patient's informed refusal must be respected regardless of the nurse's personal beliefs.
Correct action: Ensure the patient has been fully informed of the risks. Document the education provided and the refusal. Notify the physician. Explore alternative treatments (iron supplementation, erythropoietin). Do NOT coerce or continue to argue.
3
Scenario: You are preparing a medication and realize the dose ordered is 10× the normal dose. The ordering physician insists the dose is correct and tells you to give it.
Principle: Non-maleficence — do no harm. You have a professional obligation to prevent harm even when ordered by a physician.
Correct action: Do not give the medication until the dose is verified. Consult the pharmacist. Contact the charge nurse. Use the chain of command. Document your concerns. Never give a medication you believe will harm the patient simply because you were ordered to.
📌 NCLEX Application
Ethics questions on NCLEX are almost always about autonomy vs. beneficence conflicts.
NCLEX rules for ethical scenarios:
• Competent patient refuses treatment → respect refusal (autonomy wins), document, notify provider
• Patient cannot decide (unconscious, incompetent) → follow advance directive if present; if not, surrogate decision-maker
• Advance directive overrides family wishes when patient is incapacitated
• DNR does NOT mean "do nothing" — comfort care, pain management, and dignity continue
• A nurse who disagrees with a patient's decision must still respect it and provide excellent care
Common NCLEX trap: A patient who "seems confused" but is actually competent. Confusion does not equal incompetence. Patients retain decision-making capacity unless a formal assessment determines otherwise.
⚠️ The Trap — Thinking DNR Means "Do Nothing"
A Do Not Resuscitate (DNR) order means the patient has chosen not to have CPR or advanced life support interventions if their heart stops or they stop breathing. It does NOT mean:
• Stop all treatment
• Stop administering medications
• Stop monitoring
• Stop providing comfort care
• Provide less attentive nursing care
A DNR patient receives the same quality of nursing assessment, pain management, hygiene, emotional support, and family communication as any other patient. The only difference is the response to cardiac or respiratory arrest.
NCLEX will test this distinction. "A patient has a DNR — what is the priority nursing action when you find them with labored breathing?" → Assess, position, call provider, provide oxygen for comfort. Not "do nothing."