Nursing Ethics: The Complete Guide to Principles, Dilemmas and Decisions

Ethics is not an abstract subject studied once in nursing school and then forgotten. It is part of every shift. Every time a nurse seeks consent, protects confidentiality, decides which patient to see first, speaks up for someone who cannot speak for themselves, or sits with a dying person and their family, they are making ethical choices. Nurses consistently rank among the most trusted professions in public surveys in many countries, and that trust rests on ethical practice.

Ethical challenges in nursing are becoming more complex: ageing populations, advances in life-sustaining technology, cultural diversity, staff shortages, digital records, artificial intelligence, and public health emergencies all raise new questions. This complete guide explains the foundations of nursing ethics, the International Council of Nurses Code of Ethics, core ethical principles, consent and capacity, confidentiality, advocacy, truth-telling, end-of-life care, resource allocation, moral distress, cultural humility, raising concerns, and a practical framework for making ethical decisions.

What is nursing ethics?

Ethics is the study of what is morally right and wrong, good and bad, and how we should act. Nursing ethics applies ethical thinking to the specific responsibilities, relationships and situations of nursing practice. It includes:

• Professional ethics: the values, standards and duties expected of nurses, set out in codes of ethics and professional standards.
• Clinical ethics: ethical issues in the care of individual patients, such as consent, end-of-life decisions and confidentiality.
• Organisational ethics: issues arising from how healthcare organisations operate, such as staffing, resource allocation and culture.
• Public health and global ethics: issues affecting populations, such as vaccination, pandemics, health inequalities and migration of health workers.

Ethics is related to, but different from, law. Laws set minimum standards enforced by the state. Ethics often asks more of nurses than the law requires, and occasionally ethical obligations may conflict with laws or policies, creating difficult dilemmas.

The ICN Code of Ethics for Nurses

The International Council of Nurses (ICN) Code of Ethics for Nurses, first adopted in 1953 and most recently revised in 2021, is a global guide for nurses’ ethical conduct. Many national nursing organisations and regulators base their own codes on it. The code describes nurses’ fundamental responsibilities to promote health, prevent illness, restore health, alleviate suffering and promote a dignified death. It affirms that the need for nursing is universal, and that nursing care respects human rights, including cultural rights, the right to life and choice, the right to dignity and the right to be treated with respect, without discrimination.

The 2021 code is organised around four elements:

1. Nurses and patients or other people requiring care or services: respect for dignity, autonomy and rights; confidentiality; informed consent; compassion; and advocacy for equity and social justice.
2. Nurses and practice: personal accountability, maintaining competence, upholding standards of personal conduct, looking after their own wellbeing, and using technology ethically.
3. Nurses and the profession: setting and implementing standards, contributing to evidence-based practice and research, and supporting a positive practice environment.
4. Nurses and global health: valuing health as a human right, supporting universal health coverage, addressing social determinants of health, and responding to issues such as climate change and humanitarian crises.

Nurses should also know the code of conduct or professional standards set by the regulator in their own country, which are legally enforceable.

Core ethical principles

Four principles, often called principlism, are widely used in healthcare ethics:

Respect for autonomy

Autonomy means respecting people’s right to make their own decisions about their lives and bodies, based on their values and beliefs, when they have the capacity to do so. In practice, this means providing information, seeking consent, respecting refusals, and supporting people to make choices that may differ from what professionals would choose.

Beneficence

Beneficence means acting in the best interests of patients: promoting their wellbeing, relieving suffering and providing good care.

Non-maleficence

Non-maleficence means avoiding harm, often summarised as “first, do no harm”. Many treatments carry risks, so this principle involves weighing benefits against burdens and harms.

Justice

Justice means treating people fairly, distributing resources equitably, and not discriminating on grounds such as age, sex, ethnicity, religion, disability, sexual orientation, social status or ability to pay.

Other important ethical concepts in nursing include:

• Veracity: truthfulness.
• Fidelity: keeping promises and being loyal to patients’ trust.
• Dignity: recognising the inherent worth of every person.
• Accountability: taking responsibility for one’s actions and decisions.

Other ethical approaches

Principles are not the only way to think about ethics. Care ethics, which has strong roots in nursing, emphasises relationships, attentiveness, responsiveness and the specific needs of vulnerable people. Virtue ethics focuses on the character of the nurse: compassion, courage, honesty, integrity and practical wisdom. Duty-based ethics emphasises obligations and rules, while consequentialist ethics focuses on outcomes. Different cultural and religious traditions, including Ubuntu in Southern Africa, Confucian ethics and Islamic bioethics, also offer rich frameworks that emphasise community, family and relationships. Good ethical reasoning often draws on several of these perspectives.

Informed consent

Informed consent is the process by which a person with capacity agrees to a proposed intervention after receiving adequate information. Valid consent requires:

• Capacity: the person can understand, retain and weigh the relevant information, and communicate their decision.
• Information: the nature and purpose of the intervention, its benefits, significant risks, alternatives (including doing nothing), and the likely consequences of each option, in a form the person can understand.
• Voluntariness: the decision is made freely, without coercion or undue pressure from professionals or family.

Consent can be verbal, written or implied (for example, holding out an arm for a blood pressure check), and it is a continuing process: people can withdraw consent at any time. Nurses obtain consent for the care they provide daily and often play an important role in checking that patients have understood information given by other professionals and in raising concerns if they have not.

Interpreters

When patients do not speak the local language fluently, professional interpreters should be used for consent and important conversations. Using family members, especially children, as interpreters risks inaccurate information, breaches of confidentiality and pressure on the patient.

Mental capacity and decision-making

Adults are generally presumed to have capacity unless shown otherwise. Capacity is decision-specific and time-specific: a person may have capacity for some decisions but not others, and capacity can fluctuate, for example with delirium. A person is not to be treated as lacking capacity simply because they make an unwise decision.

When a person lacks capacity for a particular decision, laws in many countries require decisions to be made in their best interests, taking into account their past and present wishes, values and beliefs, and consulting family, carers and anyone with legal authority, such as an attorney or guardian. Advance decisions or advance directives, made when the person had capacity, should be respected according to local law. Nurses should be familiar with the capacity and consent laws of the country in which they practise.

Refusal of treatment

Adults with capacity have the right to refuse treatment, even if refusal could lead to serious harm or death. This can be one of the most difficult situations for nurses, whose instinct is to help. Respecting refusal involves:

• Making sure the person has the information they need and understands the consequences.
• Exploring their reasons, fears and values; sometimes refusal is based on misunderstanding, fear, pain or practical concerns that can be addressed.
• Checking capacity if there are concerns.
• Offering alternatives.
• Documenting the discussion carefully.
• Continuing to provide care, comfort and support, and leaving the door open for the person to change their mind.

Refusal on religious grounds, such as refusal of blood products by some Jehovah’s Witnesses, should be respected in adults with capacity, with exploration of acceptable alternatives. Decisions about children are more complex and are governed by specific laws.

Confidentiality and privacy

Patients share intimate information with nurses on the understanding that it will be kept confidential. Breaches of confidentiality damage trust and can cause serious harm. Key principles:

• Share information only with those directly involved in the person’s care, on a need-to-know basis.
• Do not discuss patients in public places, including lifts, canteens and public transport.
• Do not access records of people you are not caring for, including family, friends, colleagues or public figures.
• Protect electronic records: log out, use strong passwords, and never share login details.
• Never post information or images about patients on social media, even without names.
• Use secure systems for communication; avoid sending identifiable information through personal messaging apps unless approved.

Confidentiality is not absolute. Information may be disclosed with the patient’s consent, when required by law (for example, notifiable diseases or court orders), or when necessary to protect the patient or others from serious harm, such as in safeguarding concerns. Disclosures should be limited to what is necessary, and decisions should be documented and discussed with senior colleagues where possible.

Advocacy

Advocacy is central to nursing. Nurses advocate for patients by making sure their voices are heard, their rights respected and their needs met, particularly when they are vulnerable, frightened or unable to speak for themselves. Advocacy can involve:

• Speaking up when a patient’s pain is not being managed.
• Questioning a treatment plan that does not reflect the patient’s wishes.
• Making sure a patient has an interpreter.
• Challenging discriminatory behaviour.
• Raising concerns about unsafe care.
• Advocating at policy level for better services and health equity.

Advocacy requires courage, communication skills and knowledge of how to escalate concerns. It should empower patients rather than replace their voice with the nurse’s.

Truth-telling and breaking bad news

In many health systems, there has been a strong shift towards open, honest communication with patients about diagnoses and prognoses, based on respect for autonomy. However, cultural expectations vary widely. In some cultures, families traditionally receive bad news and decide what to share with the patient, seeing this as an act of protection and love.

Ethically sensitive approaches include:

• Asking patients early, before bad news arises, how much they want to know and who they want involved in discussions.
• Respecting a patient’s informed choice not to know details, while making sure they are not deprived of information they want.
• Exploring families’ concerns with empathy, explaining that patients often sense something is wrong and that secrecy can increase isolation and fear.
• Never lying to a patient who asks a direct question, while choosing words carefully and gently, and finding out what they are really asking.
• Involving the senior clinician responsible for the patient’s care, and following a structured approach to breaking bad news.

In the lead story, a nurse might respond to the patient’s question by gently asking, “What have you noticed about how you are feeling?” or “What is worrying you most?”, listening carefully, and making sure the medical team and family meet to plan honest, compassionate communication guided by what the patient wants to know.

End-of-life care

End-of-life care raises some of the most profound ethical questions in nursing, including:

• Withholding and withdrawing treatment: it is widely accepted ethically and legally in many countries that treatment which is no longer beneficial, or which the patient does not want, can be withheld or withdrawn. Most ethicists see no moral difference between not starting and stopping a treatment.
• Do-not-attempt-resuscitation decisions: these should involve the patient wherever possible, or their family when the patient lacks capacity, and be clearly documented. A DNACPR decision applies only to cardiopulmonary resuscitation; it does not mean withdrawing other care.
• Symptom control: providing adequate pain relief and sedation to relieve suffering is ethically supported, even if there is a theoretical risk of shortening life, when the intention is to relieve suffering and doses are proportionate (the principle of double effect).
• Assisted dying and euthanasia: these are legal in some countries and jurisdictions under strict conditions and illegal in many others. Nurses must know the law where they practise and their professional body’s guidance. Many jurisdictions allow conscientious objection to direct participation, while requiring nurses not to obstruct access and to continue providing care.
• Advance care planning: helping patients think about and record their wishes for future care.

Palliative care, focusing on comfort, dignity and quality of life for patients and families, is recognised by the World Health Organization as a human right and an ethical responsibility of health systems.

Resource allocation and justice

Resources in healthcare are always limited: staff, beds, medicines, equipment and time. Nurses make allocation decisions every day, such as prioritising which patient to see first. At a larger scale, triage systems, waiting lists and pandemic crisis standards involve explicit rationing.

Ethical resource allocation should be based on clinical need and fair, transparent criteria, not on social worth, wealth, connections or discrimination. During the COVID-19 pandemic, many health systems developed crisis standards of care to guide decisions about scarce ventilators and intensive care beds, raising intense ethical debate about the role of age, disability and likelihood of benefit.

Chronic understaffing creates a constant form of rationing, where nurses cannot provide all the care patients need, sometimes called “missed care”. This is an ethical issue for organisations and policymakers, not only for individual nurses, and nurses have an ethical duty to report unsafe staffing.

Moral distress and moral injury

Moral distress occurs when a nurse knows the ethically right action but feels unable to take it because of institutional constraints, hierarchy, lack of resources or other barriers. Common sources include providing care perceived as futile, inadequate staffing, witnessing poor care, and feeling unheard. Moral distress can accumulate over time, leading to burnout, compassion fatigue and nurses leaving the profession.

Moral injury is a deeper wound, arising from doing, failing to prevent, or witnessing actions that violate deeply held moral beliefs. It was widely reported among health workers during the COVID-19 pandemic. You can read more in our guide to moral injury in nursing.

Strategies to address moral distress include naming it, talking with colleagues, ethics consultation services, structured debriefing, moral resilience training, and organisational changes that address root causes. Leaders have a responsibility to create environments where nurses can act on their ethical judgement.

Cultural humility and respect for diversity

Patients bring diverse beliefs, values, religious practices and family structures that shape their healthcare decisions. Cultural humility involves lifelong self-reflection, recognising one’s own biases, being open to learning from patients, and addressing power imbalances in healthcare relationships. It goes beyond “cultural competence” checklists, recognising that individuals within any culture vary greatly. Ethical nursing respects diversity while upholding human rights, including protecting vulnerable people from harmful practices.

Conscientious objection

Some nurses may object, on grounds of conscience, to participating in certain procedures, such as abortion or assisted dying. Many jurisdictions recognise a limited right to conscientious objection for direct participation in specific procedures, but nurses must:

• Inform their employer in advance.
• Not obstruct patients’ access to legal care.
• Refer patients appropriately.
• Continue to provide care before and after the procedure, and in emergencies.
• Not impose their beliefs on patients.

Raising concerns and whistleblowing

Nurses have an ethical and professional duty to raise concerns about anything that puts patients at risk, including unsafe practice, poor care, abuse, unsafe staffing or the behaviour of colleagues. Inquiries into healthcare scandals in several countries have found that staff concerns were ignored or suppressed. Steps include raising concerns with your line manager, escalating through the organisation if not addressed, using freedom to speak up guardians or similar roles where available, and, if necessary, contacting regulators or external bodies. Many countries have laws to protect whistleblowers. Keep factual records, seek advice from your professional body or union, and remember that patient safety comes first.

Professional boundaries

The nurse-patient relationship involves trust and an imbalance of power. Professional boundaries protect patients from exploitation and nurses from compromising situations. Boundary issues include accepting significant gifts, dual relationships, sharing excessive personal information, social media contact with patients, and any form of romantic or sexual relationship with a patient, which is always unacceptable. Nurses should reflect on warning signs such as feeling special to a patient, keeping secrets, or spending unusual amounts of time with one patient, and seek supervision.

Ethics in research and technology

Nurses participating in research must uphold ethical standards, including informed consent, confidentiality, minimising risk, and approval by ethics committees. New technologies, including electronic records, telehealth, genomics and artificial intelligence, raise questions about privacy, consent, equity and accountability. See our guide to artificial intelligence in nursing.

A practical framework for ethical decision-making

When facing an ethical dilemma, a structured approach can help:

1. Identify the problem: What exactly is the ethical issue? Who is affected?
2. Gather the facts: clinical facts, the patient’s wishes and values, family perspectives, legal requirements, policies and resources.
3. Identify the ethical principles and values in tension: for example, autonomy versus beneficence.
4. Consider the options: list possible actions and their likely consequences for everyone involved.
5. Consult: discuss with colleagues, senior nurses, the multidisciplinary team, ethics committees or ethics consultation services, and professional guidance.
6. Decide and act: choose the option that is best justified, respecting the patient’s rights and wellbeing.
7. Document: record the reasoning, discussions and decision.
8. Reflect: afterwards, consider what was learned and how you feel; seek support if needed.

Ethics in the care of children

Caring for children raises distinct ethical questions. Children have rights, including the right to be heard in decisions about their care, as recognised by the United Nations Convention on the Rights of the Child. As children grow, they develop the ability to understand and make decisions, and their views should carry increasing weight. Older children and adolescents may be able to consent to some treatments themselves, depending on their maturity and the law in their country. Nurses play a central role in explaining care to children in age-appropriate ways, seeking their assent (agreement) even when parents give formal consent, and advocating for them when their interests may differ from those of their parents. Safeguarding children from abuse and neglect is an ethical and legal duty that overrides confidentiality when a child is at risk.

Ethics in mental health nursing

Mental health nursing involves particular ethical tensions between respecting autonomy and protecting people from harm. Mental health laws in many countries allow people to be detained and treated without consent in specific circumstances, such as serious risk to themselves or others. These powers carry great responsibility. Ethical mental health nursing involves using the least restrictive options, involving people in decisions as much as possible, respecting their dignity and rights, regularly reviewing the need for compulsion, minimising restraint and seclusion, and recognising the trauma that coercive interventions can cause. Recovery-oriented approaches emphasise hope, choice and partnership.

Ethics in caring for older adults

Older adults may face ageism, assumptions that they cannot make their own decisions, and pressure from families or services. Ethical care respects their autonomy and dignity, involves them in decisions, avoids unnecessary restrictions such as bed rails or locked doors without proper justification, and protects them from neglect and abuse, including financial abuse. Questions around capacity, moving into residential care, driving, and end-of-life choices are common. Nurses should be alert to elder abuse, which is often hidden, and know how to report concerns.

Global and public health ethics

Nurses work within health systems shaped by global inequalities. Public health ethics raises questions such as how to balance individual freedoms with community protection during outbreaks (for example, quarantine, isolation and vaccination requirements), how to allocate vaccines fairly between and within countries, and how to address social determinants of health such as poverty, housing and education. The ICN Code of Ethics highlights nurses’ responsibilities in relation to global health, human rights, climate change and humanitarian crises. International recruitment of nurses also raises ethical questions about the impact on health systems in source countries; the WHO Global Code of Practice on the International Recruitment of Health Personnel and the WHO health workforce support and safeguards list aim to protect countries with severe shortages. See our article on whether international nurse recruitment is ethical.

Social media and digital professionalism

Social media allows nurses to share knowledge, build networks and advocate for the profession, but it also creates ethical risks. Breaches of confidentiality can happen even without names, for example through photos showing identifiable surroundings, descriptions of unusual cases, or comments about “a patient today”. Posting in uniform, expressing discriminatory views, criticising colleagues or employers publicly, or sharing health misinformation can damage trust in nursing and lead to regulatory action. Before posting, ask: would I be comfortable if my regulator, my employer, my patients and my family saw this? Keep professional and personal accounts separate, check privacy settings, and never accept friend requests from current patients.

Ethics committees and consultation

Many hospitals have clinical ethics committees or ethics consultation services that provide advice on difficult cases, develop policies and educate staff. Nurses can usually request a consultation directly. Ethics consultation does not make decisions for clinicians but helps clarify the issues, facilitate discussion among the team, patient and family, and identify ethically acceptable options. Nurses’ perspectives, grounded in close knowledge of patients and families, are valuable in these discussions, and nurses are increasingly represented on ethics committees.

Case study: the patient who wants to go home

Mr A, aged 78, lives alone and was admitted after a fall. He wants to go home, but the team is worried he will fall again. His daughter wants him to move to a care home. Ethical reasoning might proceed as follows: first, assess whether Mr A has capacity to decide where to live, recognising that an unwise decision is not proof of incapacity. If he has capacity, his choice should be respected, and the team’s role is to reduce risk at home through physiotherapy, equipment, home modifications, care support and a personal alarm, while documenting the discussion of risks. If he lacks capacity, a best-interests decision is made, taking his wishes and values seriously and choosing the least restrictive option. Throughout, the nurse supports Mr A and his daughter with compassion, recognising the daughter’s genuine concern.

Case study: the colleague who smells of alcohol

A nurse notices that a colleague smells of alcohol at the start of a shift and seems unsteady. Loyalty to the colleague conflicts with the duty to protect patients. The ethical course is to act promptly to protect patients, by informing the nurse in charge or manager confidentially so the colleague does not provide care while impaired, while treating the colleague with compassion, recognising that addiction is a health condition and that many organisations have supportive pathways for staff with substance use problems. Ignoring the situation risks patient harm and fails the colleague, who may need help.

Case study: the unsafe shift

A charge nurse arrives for a night shift to find that two of the five scheduled nurses have called in sick and no replacements are available. The ward has 32 patients, several of whom are acutely unwell. Ethical principles of beneficence, non-maleficence and justice are all under strain. The ethical response involves escalating immediately to the senior nurse on duty and documenting the staffing levels and the risks; prioritising care based on clinical need; asking for support from other areas, such as an outreach team; considering whether admissions should be paused; communicating honestly with the team about priorities; and completing an incident report afterwards. The charge nurse is not personally responsible for the organisation’s staffing failure, but is responsible for raising the alarm and making the best possible decisions within the situation. Afterwards, a debrief helps staff process moral distress and supports organisational learning.

Case study: the request for a “white lie”

A patient with dementia repeatedly asks for her husband, who died two years ago. Each time she is told he has died, she grieves as if hearing it for the first time. Some families and staff choose to say “He is at work” to avoid distress. This raises a tension between truthfulness and kindness. Many dementia care experts suggest a middle path: rather than repeatedly confronting the person with painful facts or telling outright lies, respond to the emotion behind the question (“You are thinking about him. Tell me about him”), offer comfort, and redirect gently. Teams should agree on an approach that respects the person’s dignity and wellbeing, documented in the care plan, so that responses are consistent and compassionate.

Developing your ethical competence

Ethical competence grows through education, experience and reflection. Ways to strengthen it include:

• Reading your professional code regularly, not just once.
• Discussing real cases in team meetings, journal clubs or ethics rounds.
• Reflecting on situations where you felt uncomfortable, and what you would do differently.
• Attending ethics training and seeking out ethics consultation.
• Learning about the cultures, religions and values of the communities you serve.
• Finding mentors who model ethical practice and courage.
• Staying informed about laws affecting your practice, such as capacity, consent, data protection and end-of-life legislation.

Key messages

• Ethics is part of everyday nursing, not just dramatic dilemmas.
• The ICN Code of Ethics and your national code guide your professional conduct.
• Respect autonomy, act in patients’ best interests, avoid harm and treat people fairly.
• Consent must be informed, voluntary and given by someone with capacity.
• Protect confidentiality, including online.
• Advocate for patients, raise concerns, and seek support when facing moral distress.
• Use a structured framework and consult others when decisions are difficult.

Ethics and documentation

Good documentation is an ethical as well as a legal responsibility. Accurate, timely and honest records support continuity and safety of care, show how decisions were reached, and protect patients’ interests. Ethical documentation means recording facts rather than opinions or judgements, avoiding stigmatising language about patients (for example, describing someone as “non-compliant” or “difficult” rather than describing what happened and why), never altering records after the event without clearly marking the change and its reason, and recording discussions about consent, refusals, capacity and end-of-life wishes clearly. Language in records shapes how other professionals see patients; respectful, accurate language is part of respecting dignity. See our guide to nursing documentation.

Ethics and self-care

The ICN Code of Ethics recognises that nurses must look after their own health and wellbeing in order to provide safe care. This is not selfishness; it is an ethical responsibility. Exhausted, burned-out nurses are more likely to make mistakes and less able to offer compassion. Taking breaks, seeking support after distressing events, setting boundaries and speaking up about unsafe working conditions are ethical actions that protect both nurses and patients.

Ethics in humanitarian and disaster settings

Nurses working in conflict zones, refugee camps and disasters face extreme ethical pressures: overwhelming need, scarce supplies, threats to their own safety, and pressure from armed groups or authorities. International humanitarian law and principles of humanity, neutrality, impartiality and independence guide care in these settings. Nurses must treat people based on need alone, regardless of which side they are on, and attacks on health workers and facilities are violations of international law. Organisations deploying nurses should provide ethical preparation, support and psychological care before, during and after deployment. The courage and integrity of nurses in these settings show nursing ethics at its most demanding.

Ethical nursing is ultimately about seeing each person as someone with their own story, values and dignity, and letting that shape every decision, however small.

Frequently asked questions

What is the difference between an ethical dilemma and an ethical problem?

An ethical dilemma involves a choice between two or more options that each have ethical justifications and drawbacks. An ethical problem may have a clear right answer but be difficult to carry out because of barriers.

Can a nurse refuse to care for a patient?

Nurses must not refuse care on discriminatory grounds. Limited conscientious objection may apply to specific procedures. Nurses may decline unsafe assignments but must escalate concerns appropriately and not abandon patients.

What should I do if a family asks me to hide information from a patient?

Listen to their concerns, explain the patient’s right to information, find out what the patient wants to know, and involve the senior clinician and team in planning communication.

Is it ethical to restrain a patient?

Restraint, whether physical, chemical or environmental, should be a last resort, used only when necessary to prevent serious harm, in the least restrictive way, for the shortest time, within the law and local policy, and with careful monitoring and documentation.

Where can I get help with an ethical issue?

Talk to senior colleagues, ethics committees or consultation services, professional associations, unions, or your regulator’s guidance.

But what if doing the right thing puts my job at risk?

Acting ethically can sometimes feel risky, especially when raising concerns about colleagues, managers or organisational practices. Protect yourself by following formal processes, keeping factual records, seeking support from your professional body or union, and using whistleblowing protections where they exist. Remember that professional codes and regulators place patient safety first, and that failing to act can itself have serious professional consequences. You do not have to act alone: courage is easier when shared with colleagues who hold the same values.

Related: Ethical dilemmas in nursing: examples · Moral injury in nursing

Sources: International Council of Nurses (Code of Ethics for Nurses, 2021 revision), World Health Organization (palliative care; Global Strategic Directions for Nursing and Midwifery), Beauchamp and Childress (Principles of Biomedical Ethics), UNESCO Universal Declaration on Bioethics and Human Rights, Jameton A (moral distress), World Medical Association Declaration of Helsinki (research ethics).