Aimee Milliken PhD, RN, HEC-C

When you think about ethics, what comes to mind? You may imagine famous cases you learned about in school, like Karen Ann Quinlan, Nancy Cruzan, or Terri Schaivo. You might also think about interventions like medical aid in dying, gene editing, or euthanasia. Chances are, you might also remember cases you’ve seen in your own practice that have stayed with you – families who disagreed about their loved ones’ care at the end of life, cases where you weren’t sure you did the “right” thing, or even cases where your hospital ethics committee was called. 

Traditional ethics education tends to turn to the classic cases in bioethics – the dilemmatic and publicity-drawing end of life debates, familial conflicts, and prognostic disagreements that generate headlines and are written about in textbooks. While these cases are interesting and can provide useful fodder for discussion, they represent a very small proportion of the actual ethical conflicts that clinicians, and especially nurses, see in their day-to-day practice. 

Because of this dynamic, and because of my experiences with moral distress as a new graduate nurse, I became interested in the idea of everyday ethics during my doctoral studies. It struck me that preparing nurses to address dilemmas was exciting, but less useful than preparing nurses to recognize and address the ethical content in their routine practice. At the bedside, I was bothered by the sense that I was failing my patients, especially at the end of life, not by cases that were in the news. At the advice of my mentor, Dr. Pam Grace, I began reading the work of James Rest,¹ whose Four-Component Model of ethical action inspired me to analyze the concept of ethical sensitivity, which eventually led to my work on ethical awareness.^2,3

At its most basic level, ethical awareness involves the nurse’s ability to recognize the ethical content in every nursing action, ranging from the most routine tasks like changing bed linens, all the way to the most ethically impactful, like terminal extubation (removing a breathing tube at the end-of-life). Every action we take as a nurse ought to be grounded in our professional goals,⁴ and in the furtherance of patient good. The idea is that if we are able to pick up on the ethical content of everything we do, we will ideally identify potential ethical conflicts earlier, either preventing or making them more amenable to intervention and resolution. Anticipating an ethical problem requires ethical awareness, and intervening on the issue involves moral agency. Empowering nurses as moral agents, ideally, can mitigate moral distress.⁵

Ethical awareness is closely aligned with the idea of preventive ethics. Preventive ethics holds that the sources of ethical conflict are largely predictable and often preventable.^6,7 For example, some work has been done to develop “triggers” of ethical conflict that could trigger an ethics consult.^6,8 Preventive ethics rounding or proactive ethics consultation are other models of early ethics intervention.⁹

While these models hold promise, a limiting factor to their utilization is funding. The availability of dedicated (and paid) ethics resources remains limited, particularly in community hospitals and more rural areas.  As such, emphasizing nursing ethics education across pre- and post-licensure programs is critical in ensuring that nurses entering nursing and advanced practice are equipped with a foundational level of ethical awareness so that they are prepared for the ethical issues they will face. This does not require that we turn all nurses into ethicists, but that we prepare nurses to be facile in the tools and language of nursing ethics. 

References

1.  Narvaez D, Rest JR. The four components of acting morally. Moral behavior and moral development: An introduction. Handbook of moral and character education. Published online January 1, 1995:385-400.

2.  Milliken A, Grace P. Nurse ethical awareness: Understanding the nature of everyday practice. Nurs Ethics. 2017;24(5):517-524. doi:10.1177/096973301561517

3. Milliken A, Ludlow L, DeSanto-Madeya S, Grace P. The development and psychometric validation of the Ethical Awareness Scale. J Adv Nurs. 2018;74(8):2005-2016. doi:10.1111/jan.13688

4.  American Nurses Association. Code of Ethics for Nurses. 2025. https://codeofethics.ana.org/home

5. Milliken A. Ethical Awareness: What It Is and Why It Matters. Online J Issues Nurs. 2018;23(1). doi:10.3912/OJIN.Vol23No01Man01

6.  Epstein EG. Preventive Ethics in the Intensive Care Unit. Rushton CH, ed. AACN Advanced Critical Care. 2012;23(2):217-224. doi:10.4037/NCI.0b013e31824b3b9b

7.  Forrow L, Arnold RM, Parker LS. Preventive Ethics: Expanding the Horizons of Clinical Ethics. The Journal of Clinical Ethics. 1993;4(4):287-294. doi:10.1086/JCE199304402

8. Milliken A, Courtwright A, Grace P, Eagan-Bengston E, Visser M, Jurchak M. Ethics Consultations at a Major Academic Medical Center: A Retrospective, Longitudinal Analysis. AJOB Empirical Bioethics. 2020;11(4):275-286. doi:10.1080/23294515.2020.1818879

9. Pavlish C, Brown-Saltzman K, Fine A, Jakel P. Making the Call: A Proactive Ethics Framework. HEC Forum. 2013;25(3):269-283. doi:10.1007/s10730-013-9213-5