Every nurse eventually faces a situation where there’s no perfect answer. A patient refuses life-saving treatment. A family asks you not to tell their mother she has cancer. You’re told to look after more patients than you can safely manage. These are ethical dilemmas, and how you handle them matters for patients, for you and for your registration.
This guide covers the core principles, a simple decision framework and 10 realistic scenarios.
The four core principles
- Autonomy: respecting a person’s right to make decisions about their own care.
- Beneficence: acting in the patient’s best interests.
- Non-maleficence: avoiding harm.
- Justice: treating people fairly and distributing resources equitably.
Professional codes, such as the ICN Code of Ethics for Nurses and national codes like the NMC Code in the UK, build on these principles.
A simple framework for difficult decisions
- Identify the problem: what exactly is the conflict?
- Gather the facts: clinical details, the patient’s wishes, capacity, law and policy.
- Identify who’s involved: the patient, family, team and organisation.
- Consider the options and their likely consequences.
- Apply principles, codes and law.
- Seek support: your manager, senior colleagues, ethics committee or legal team.
- Act, document and reflect.
10 ethical dilemmas nurses face
1. A patient with capacity refuses treatment
An adult with capacity refuses a blood transfusion for religious reasons. Respect for autonomy means the refusal must be respected, provided the decision is informed. Make sure they understand the consequences, explore alternatives, involve the medical team and document carefully.
2. Family asks you to hide a diagnosis
Relatives ask you not to tell an older patient she has cancer. In many cultures this is common, but patients generally have a right to information about their health. Explore what the patient wants to know, involve the team, and use sensitive communication rather than deception.
3. Unsafe staffing
You’re asked to care for far more patients than you can safely manage. Raise concerns immediately with the nurse in charge, document them, prioritise care and use your organisation’s escalation process. Professional codes require you to raise concerns about patient safety.
4. A colleague is impaired
A colleague smells of alcohol on shift. Patient safety comes first. Raise it with the nurse in charge or manager straight away, without confronting the colleague in front of patients.
5. Confidentiality vs safety
A patient tells you they plan to harm someone. Confidentiality isn’t absolute; you may need to share information to prevent serious harm. Follow policy and seek senior advice.
6. Patients who can’t pay
In settings where treatment depends on payment, a patient in an emergency arrives without money. Professional ethics and, in many countries, the law require emergency care to be given. Escalate to management and social work.
7. Requests for gifts or money
A grateful family offers you a large sum of money. Most codes and employers discourage accepting significant gifts because they can affect professional boundaries. Politely decline or follow your employer’s gifts policy.
8. End-of-life decisions
A family insists on continuing aggressive treatment that the team believes won’t help. Good communication, involving palliative care and understanding the family’s fears are key. Decisions should be shared and in the patient’s best interests.
9. Social media
A colleague posts a photo from the ward showing a patient’s bed number. Even partial details can identify patients. Ask for it to be removed and report it if needed.
10. Conscientious objection
Some nurses object to participating in specific procedures. Many jurisdictions allow conscientious objection in limited areas, but you must not obstruct the patient’s access to care and must still provide emergency care. Inform your manager in advance.
Protecting yourself ethically and legally
- Know your professional code and local law.
- Document decisions, discussions and escalations.
- Never act alone on major ethical decisions; involve the team.
- Use clinical supervision and reflection to process difficult cases.
Related guides
- NMC CBT practice questions (consent, capacity and confidentiality)
- How to document refusals and incidents