Professional Role · Topic 8 of 21

Ethical Principles & Decision-Making

Professional role · clinical ethics

Ethical Principles & Decision-Making

Weigh autonomy, beneficence, nonmaleficence and justice; a capable patient's informed choice usually prevails, and double effect permits relief that may foreseeably shorten life.

Key numbers

Autonomy, beneficence, nonmaleficence, justice4 principles

01 · What it isAutonomy, beneficence, nonmaleficence, justice

The four principles: autonomy (respect the capable patient's self-determination), beneficence (act for the patient's benefit), nonmaleficence (avoid harm; weigh benefits against burdens) and justice (fair, equitable distribution of care and resources).

02 · The ruleA capable patient's informed choice usually prevails

When a capable, informed patient's choice conflicts with the clinician's view of benefit, autonomy generally prevails — overriding it is hard paternalism; keep caring for the patient and do not abandon them.

03 · Defined byDouble effect: intend relief, only foresee harm

Double effect permits an act with good and bad effects if the act is good or neutral, only the good is intended, the good does not come through the bad, and the reason is proportionate.

The rules

Know these

Withholding and withdrawing are ethically equivalent must knowThere is no ethical difference between withholding and withdrawing a treatment; when an intervention no longer serves the patient's goals, stopping it is appropriate.

Ethics consultants advise; they do not decideAn ethics consultation clarifies values and facilitates decisions when there is disagreement or uncertainty; consultants are advisors, not decision-makers, and the team need not follow the recommendation but should explain why not.

Principles are prima facie — weigh themEach principle is a prima facie duty, binding unless it conflicts with another; weigh them by content and context — a painful IV catheter in shock is justified because beneficence outweighs nonmaleficence.

Request an ethics consult for unresolved conflictRequest ethics consultation when no surrogate exists or who it is is disputed, a treatment disagreement persists, or a surrogate's decision seems contrary to the patient's wishes or interests; tell the patient it was requested.

Conscientious objection has limitsA clinician may decline to provide a service on grounds of conscience but must still give emergency care, honor informed refusals of life-sustaining treatment, avoid discrimination, disclose all options, and generally refer the patient.

What it is

Core idea

Autonomy grounds consent, truth-telling and confidentialityRespect for autonomy is the basis of informed consent, truth-telling and confidentiality; a patient may also autonomously choose to have information go to, and decisions made by, a family member — ask the patient.

Justice: fair allocation of scarce resourcesJustice in clinical ethics is mainly distributive: fair, equitable allocation of scarce resources such as equipment, tests, drugs, organs and clinician time, and fair care of uninsured patients.

ANA Code 2025: ten provisionsThe 2025 ANA Code of Ethics for Nurses has 10 provisions: 1 — dignity and self-determination; 2 — primary commitment to the patient; 3 — advocacy for the patient's rights, privacy and safety.

Moral distress: knowing the right act, constrainedMoral distress occurs when a clinician believes they know (or is unsure of) the ethically correct action but is constrained from taking it; common triggers are end-of-life treatment choices, inadequate staffing and value conflicts.

Management

Orders

Four-box method for an ethics problemWork an ethical problem with the four-box method (Jonsen): medical indications, patient preferences, quality of life as the patient sees it, and contextual features — family, culture, religion, finances and law.

Double effect or euthanasia?

Commonly confused

What is intended	Relief of pain or dyspnea
Hastened death	Foreseen, not intended
Is death the means?	No — relief comes from the drug's effect
Same dose, same drug?	Permissible

Commonly confused

Tell apart

Soft paternalism protects a nonautonomous patientSoft paternalism — acting to benefit a nonautonomous patient (cognitive dysfunction from severe illness, depression, drug addiction) — is defensible if consistent with the patient's values; hard paternalism against a capable, informed patient is not.

More detail

Reference

Show 5 reference facts

Beneficence is a positive duty — to prevent and remove harm and promote welfare — whereas nonmaleficence is the duty not to harm, applied by rejecting inappropriately burdensome interventions.

Simply listing options and letting the patient pick (consumerism) abandons the patient; the clinician should give a recommendation grounded in the patient's goals.

Truth-telling includes disclosing medical errors that harmed the patient, with an apology; information may be paced to the patient's wishes but not permanently withheld.

Used appropriately, opioids rarely cause clinically important respiratory depression; the mistaken belief that symptom relief hastens death leads clinicians and families to undertreat pain.

In the 2025 ANA Code, Provision 5 covers the nurse's duties to self (safety, integrity, competence), Provision 7 policy and research, Provision 9 social justice and legislation, and Provision 10 global health.

Pearl

Intent separates palliation from killing: treat the symptom and accept a foreseen risk — never aim at death.

Sources · Varkey B. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract 2021;30:17–28 · Stanford Encyclopedia of Philosophy — Doctrine of Double Effect (conditions; euthanasia vs pain relief; §5.1 palliative care) · AMA Code of Medical Ethics Opinion 10.7.1 — Ethics Consultations · AMA Code of Medical Ethics Opinion 2.1.2 — Decisions for Adult Patients Who Lack Capacity · American Nurses Association — Code of Ethics for Nurses (2025), table of contents with all 10 provisions · AMA Code of Medical Ethics Opinion 1.1.7 — Physician Exercise of Conscience · AACN — Moral Distress in Nursing: What You Need to Know · AMA Code of Medical Ethics Opinion 5.3 — Withholding or Withdrawing Life-Sustaining Treatment · AMA Code of Medical Ethics Opinion 2.1.3 — Withholding Information from Patients · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).