Nursing Ethics

Nursing Ethics is the comprehensive set of ethical principles, values, and rules that examine the moral foundations of the nursing profession and guide professional practice. Since the 20th century, it has gained importance alongside the evolving functions of the profession, addressing the theoretical, practical, and research dimensions of nursing within a moral framework as a human-centered health discipline.

Philosophical Foundations

Nursing is a scientific health discipline linked to philosophy, built upon the concepts of person, environment, health-illness, and nursing. As an applied branch of ethics, nursing ethics examines what constitutes good nursing practice, the barriers to such practices, and the professional responsibilities of nurses. Socrates’ conception of virtue grounded in knowledge underpins nursing ethics; the view that the knowledgeable person is virtuous and guided toward right actions underscores the importance of moral reasoning in nursing care.

Nursing ethics perceives the individual as a whole encompassing biological, psychological, social, cultural, and spiritual dimensions. The nurse acknowledges the uniqueness of each person in terms of their values, beliefs, attitudes, and behaviors and believes in the individual’s right to the highest quality of care. This belief is an ethical imperative of nursing care. Ethics guides decision-making processes in nursing, interprets moral norms, and directs professional practices toward what is good and right.

According to Jacques Leclercq, modern philosophy addresses issues directly related to the human being; therefore, nursing ethics adopts a person-centered approach that prioritizes individual values and needs. Charles Sanders Peirce’s methods of belief fixation have influenced the historical development of nursing ethics, particularly in how authoritarian beliefs have shaped professional moral reasoning.

Nursing bears the responsibility of planning, implementing, and evaluating processes that preserve, promote, and restore the health and well-being of individuals, families, and communities. In this process, nursing science and art are carried out in accordance with ethical values and principles. Nursing ethics does not limit itself to humans alone; other living beings and environmental elements are also incorporated into the value system, thus intersecting with fields such as ecoethics and bioethics.

Ethical Principles

Nursing ethics is founded on ethical principles, which are fundamental moral truths that guide intentions and actions. These principles enable nurses to understand the moral dimension of their profession, develop moral sensitivity, and fulfill their professional responsibilities to deliver high-quality care to society. The key ethical principles to be considered in nursing practice are autonomy, beneficence, non-maleficence, honesty, confidentiality, justice, and fidelity.

Autonomy

It is the right of the individual to make free choices regarding matters that affect their own life. An autonomous individual is respected, sets their own goals, makes decisions about action plans, and enjoys the freedom to act in accordance with their preferences. For autonomy to be upheld, at least a minimum level of these four elements must be present.

In health care, autonomy is supported by informed consent; patients have the right to make free decisions after being informed about the risks, alternatives, and outcomes of treatment. However, the structure of health systems that render individuals dependent—for example, mandatory changes of clothing, violations of privacy, fixed meal and bathing times—can threaten autonomy. Nurses are obligated to protect patients’ autonomy, defend their individual rights, and support informed consent processes. Autonomy preserves human dignity and strengthens trust in the patient-nurse relationship.

Beneficence

It requires nurses to act in ways that benefit patients. This principle encompasses doing good, preventing harm, and eliminating suffering. Nurses protect patients’ rights, prevent harm, and focus on enhancing the individual’s health and well-being throughout care processes. Beneficence is both a moral and legal obligation of nurses’ professional roles. For instance, nurses apply beneficence by ensuring patient safety, maintaining communication, meeting basic needs such as nutrition, elimination, hygiene, mobility, and sleep, and preparing patients for a peaceful death during terminal stages.

Non-Maleficence

Closely linked to beneficence, it involves avoiding intentional harm, minimizing risks of harm, and preventing harms that may arise during efforts to achieve benefit. Rooted in the Hippocratic tradition, this principle is held above all others by ethical scholars. For example, vaccinations may cause short-term pain but contribute to long-term health; in such cases, the expected benefit outweighs the harm. Similarly, surgical interventions may cause temporary harm but provide long-term benefits such as saving life or reducing pain. Nurses are obligated to minimize harm throughout care processes.

Honesty

It is the principle of telling the truth and supports respect, open communication, trust, and shared responsibility. Nurses advocate for patients’ right to receive accurate and understandable information about their diagnosis, treatment, and prognosis. Honesty forms the foundation of the patient-nurse relationship; lying severely damages this relationship. According to Martin Buber, honest communication removes barriers between people and enables genuine relationships. Nurses must act honestly to maintain patients’ trust.

Confidentiality

It is related to privacy and requires that an individual’s personal information not be shared without consent. Confidentiality preserves the individual’s dignity and supports their ability to control their own life. The International Council of Nurses (ICN) recommends that nurses maintain the confidentiality of personal information and act with prudence when necessary. The Nightingale Pledge also emphasizes confidentiality. However, the principle of confidentiality may be questioned when there is a risk of harm to innocent individuals. In particular, with electronic record systems, nurses must be vigilant to avoid accidental breaches of confidentiality.

Justice

It entails providing equal, fair, and appropriate care to individuals. Nurses are responsible for ensuring equitable distribution of resources and services among patients with the same diagnosis. Justice observes rights and legal compliance and is grounded in the equality of individuals. This principle requires nurses to avoid discrimination in care processes and to provide all patients with equal conditions.

Fidelity

It expresses commitment and adherence to promises made. Nurses act with fidelity toward society, the profession, their employing institution, and patients. This principle sustains an environment of trust. Fidelity includes adherence to professional ethical codes, loyalty to institutional policies, and keeping promises made to patients.

These principles assume that nurses respect the uniqueness and value of individuals. Ethical principles ensure that nursing practices meet professional and ethical standards, strengthen professional autonomy, and enhance nurses’ job satisfaction. Moreover, ethical principles support nurses in maintaining consistency in clinical practice and reinforcing their professional identity.

Ethical Theories

Nursing ethics draws upon ethical theories that help understand the sources of moral thought and behavior. Two major theories form the foundation of nursing ethics:

• Utilitarianism: It is grounded in the naturalistic school and evaluates the morality of an action based on its consequences. According to Jeremy Bentham, the founder of modern utilitarianism, actions are right if they increase happiness and reduce suffering; otherwise, they are wrong. John Stuart Mill defines virtuous actions as those that maximize individual happiness. Utilitarianism aims to maximize overall good and prioritizes patient benefit in nursing. For example, a nurse may make decisions in a patient’s treatment considering the broader public health. Utilitarianism is divided into act utilitarianism (focusing on the outcomes of specific actions) and rule utilitarianism (adhering to rules that promote the greatest good).

• Deontology: It is a rationalist approach that judges the morality of an action based not on its consequences but on its nature and the intention behind it. According to Immanuel Kant, ethical principles are universal and absolute and must be applied in all situations. Much of nursing ethics is based on Kantian principles that emphasize patient autonomy, dignity, and rights. Deontological approaches, being duty and responsibility oriented, form the foundation of professional ethics. For example, a nurse may choose not to administer a treatment the patient refuses, respecting their autonomy; this decision is viewed as a moral duty regardless of the outcome.

These theories guide nurses in decision-making when facing ethical dilemmas. For instance, in controversial issues such as euthanasia, utilitarianism evaluates actions based on societal benefit, while deontology adheres to universal moral rules. Nursing ethics integrates these theories to adopt an approach that considers both individual and societal well-being.

Historical Development and the Nursing Pledge

The origins of nursing ethics lie in the profession’s historical role as a morally centered health discipline responding to human suffering. Nursing emerged from social needs and has been influenced by religion, gender, and war. The first ethical codes of the profession were shaped by the “Nightingale Pledge,” created in 1893 by Lystra Gretter and inspired by Florence Nightingale’s philosophy. This pledge, adapted from the Hippocratic Oath, reflects the social and religious values of its time, including compassion, self-sacrifice, obedience, composure, faithfulness, and kindness. The original pledge carried religious overtones through phrases such as “I solemnly pledge before God,” and its emphasis on assisting physicians was criticized as limiting nursing autonomy. The pledge has also been debated due to its association with nursing as a female profession and traditional gender roles.

With increasing scientificization, certain phrases in the pledge (e.g., “assistant to the physician” and “pure demeanor”) were removed in 1935, and ethical codes were revised. The International Council of Nurses (ICN) established its code of ethics in 1953 and updated it in 1965, 1973, 2005, and 2012. The ICN nursing pledge of 1965 is recited at graduation ceremonies in Türkiye. This pledge includes ethical principles such as equality, human dignity, autonomy, confidentiality, non-maleficence, and beneficence, but omits some principles such as advocacy, truthfulness, and aesthetics. The Turkish Nurses Association (THD) published Türkiye-specific ethical principles in 2009 (non-maleficence-beneficence, autonomy-respect for the individual, justice-equality, confidentiality-secrecy), but the pledge itself has not been updated.

Although the nursing pledge serves as a guide shaping the profession’s responsibilities, it has been criticized for gendered approaches—viewing nursing as a female profession—and its emphasis on assisting physicians. For example, the original pledge’s phrase “assistant to the physician” was seen as undermining nurses’ autonomy. It has also been noted that the pledge reflects an American-centric perspective and has not been accepted in some countries, such as the Soviet Union and Japan.

In Türkiye, nursing was officially defined as a female profession until 2007, reinforcing the gendered perception of the profession. Today, it is recommended that the pledge be updated to align with universal ethical codes and social conditions. During this process, involving all nurses in determining ethical principles, establishing a shared understanding through methods such as the Delphi technique, and integrating these principles into educational programs are essential. The nursing pledge is more than a text recited at graduation ceremonies; it is an internal source of motivation that reminds nurses of their personal and professional responsibilities.

Impact on Professional Practice

Nursing ethics guides professional practices and behaviors. Ethical principles enable nurses to focus on patient needs, exercise independent decision-making, and effectively apply professional knowledge. For example, the principle of autonomy encourages patient participation in treatment processes, while confidentiality protects patient privacy. The principle of justice ensures equitable distribution of resources, and fidelity strengthens professional commitment. Nursing ethics strengthens the patient-nurse relationship, fosters a climate of trust, and supports professional autonomy.

Ethical codes established by the ICN and THD define nurses’ responsibilities toward individuals, families, communities, the profession, and other health care workers. Nurses carry broad responsibilities including promoting individual health, protecting vulnerable groups, participating in the development of laws and policies, aligning scientific and technological advances with human rights, and preserving the natural environment. Additionally, they fulfill duties such as developing professional standards, contributing to research, maintaining competence, and collaborating with colleagues.

Nursing ethics holds a significant place in professional education. Emphasizing ethical principles in nursing curricula, establishing ethics committees, and prioritizing this area by professional organizations enable nurses to deliver ethically grounded care. This enhances nurses’ understanding of their responsibilities, facilitates the delivery of high-quality care to society, and increases their job satisfaction.