cost and end-of-life care • summer 2011 121The Ethical .docx

cost and end-of-life care • summer 2011 121
The Ethical
Implications of
Health Spending:
Death and
Other Expensive
Conditions
Dan Crippen and
Amber E. Barnato
Overview
In this essay I ask the reader to consider the “end of
life” as a life stage, rather than as a health state. At
one end of the life course is childhood and at the other
end is elderhood. The basic inter-generational social
compact in most societies is that working adults take
care of their children and their parents, and count on
their children to do the same for them. In developed
countries, these obligations are met in part through
government programs, with taxpayers funding signifi-
cant portions of education, health care, and income
support.
The financing of these public programs, in addition
to other public services, involves ethically charged
trade-offs. In the United States, public outlays on
behalf of children and the elderly span roughly the
same number of years, but with very different levels
of spending. Cross-sectionally, transfers from work-
ers (via taxes) go more to the elderly in the form of
Medicare and Social Security income than to children

in the form of public education and means-tested
health insurance (e.g., Medicaid, SCHIP). Longitu-
dinally, delayed “transfers” to these same children are
manifest as better or worse economic conditions once
the children become workers. If current workers, in
addition to providing for the young and old through
taxpayer-funded social programs, manage to save as
well by reducing their own consumption of goods and
services, then future generations are likely to be better
off since these current savings are invested in capital
which will allow the economy to grow (faster). In con-
trast, if individuals, institutions, or governments bor-
row for consumption today, then future generations
are likely to be worse off since current consumption
may reduce economic growth in the future and, in the
case of public borrowing, additionally obligate future
taxpayers to fund the cost of expenditures we make
today.
In the United States, health care spending is a criti-
cal component of examining both these intra- and
inter-generational transfers. At present we spend
much more on health care, and in total, for the elderly,
Dan Crippen, Ph.D., is the newly appointed Executive Di-
rector of the National Governors Association. He has held
various posts in the public sector, including Chief Counsel
to the Senate Majority Leader, Assistant to the President and
Domestic Policy Advisor, and Director of the Congressional
Budget Office. Over the last decade, he has worked primarily
in the private sector with various organizations providing or
financing health care. Amber E. Barnato, M.D., M.P.H.,
M.S., is an Associate Professor of Medicine and Health Policy
and Management at the University of Pittsburgh, and was a
Visiting Scholar at the Congressional Budget Office during
Dan Crippen’s tenure as Director.

122 journal of law, medicine & ethics
S Y M P O S I U M
than we do for educating and ensuring safety-net
health care for our youth, thus posing the question
of whether we are spending “enough” on the young.
Moreover, by incurring large budget deficits at the fed-
eral level, in part to continue supporting health care
for the elderly (which constitutes a large and growing
part of the total budget), we are pushing off the pay-
ment for some of current health care spending on the
elderly to future generations.
The primary driver of increased health care costs
for the elderly is not spending for those who died,
but spending for all beneficiaries. Secular trends in
Medicare spending reveal that spending on behalf of
beneficiaries who die during the year has been a stable
27% for decades. Although those who die incur a dis-
proportionate share of total spending, the drivers of
cost growth affect survivors and decedents identically.
Increasing health care spending on the elderly who are
in the “end of life” life-stage (not just the “end of life”
health state) will crowd out investments in current and
future generations of children. The inter-generational
impact of health care spending on those who are in the
“end of life” life stage may have greater ethical impli-
cations than the narrow “futility” debate surounding
those who are in the “end of life” health state.
The Issue
Giving, and accepting, the assistance of others is a com-

mon human experience. Whether as children, when
education and the essentials of life are provided by
adults, or as retirees who receive financial and physi-
cal aid in their later years, virtually all of us experience
both the give and take of life. Historically, much of this
support has been voluntarily provided by familial sup-
port and bequests, or by charitable contributions and
institutions, including those of the church. In more
successful societies with higher income, the elderly
may also have savings to consume in retirement.
One of the hallmarks of “economically developed”
civilizations is a large component of public, govern-
mental transfer of resources, from those who are
working to those who are largely not. In most coun-
tries both culture and government shape these trans-
fers, subject to societal and legal compacts between
and across generations.
Altogether, these public and private reallocations of
resources can consist of real property (land, housing,
public roads), financial resources (credit and cash), or
transfers, including direct services (bequests, educa-
tion, health care).
In the United States, children are provided a combi-
nation of public and private resources. The lion’s share
of funding for education, especially through high
school, comes from state and local taxes. The provi-
sion of food, clothing, housing, and health care are
mostly provided by parents, but federal programs for
food stamps, school lunch programs, housing vouch-
ers, Medicaid, and SCHIP contribute to lower-income
families.

The elderly are typically supported with public pro-
grams of cash transfers, primarily social security, and
reimbursement for health care through Medicare and
Medicaid. By increasing amounts, governments of all
types are providing income and health care for their
former employees, now retirees. Altogether, public
programs for health care provide nearly half of the
annual costs for all health care in the United States.
The funding for these programs, including for retir-
ees, comes largely from taxes on current workers, or
from borrowing.
The moral or ethical implications of these realloca-
tions, might be examined across both current popu-
lations (living citizens of differing ages, for example),
as well as across generations over longer periods of
time. As there are always a finite number of resources
at a given point in time, current spending reflects the
choices we make among those in the current popula-
tion who cannot fend for themselves — for example,
the more we spend on our parents after they retire, the
less we have for our children.
The basic compact in the United States between the
current working population and their dependents has
been that workers pay or provide for their children
and help support their parents. As workers retire, they
depend on their working children to pay taxes to sup-
port them through public programs, whatever private
transfers they receive, and a ready market to sell the
non-cash assets they have accumulated. As support
moves from private and familial to public and govern-
mental, the association between workers and depen-
dents becomes less direct since the reallocations occur
within the larger society.

Figure 1 illustrates the typical pattern in the United
States of consumption of resources, either directly or
as provided by others, and the creation of resources
as reflected by labor income. The total available for
consumption is determined by the total production
of goods and services of those working, i.e., the size
of the economy. Across the current population the
amount consumed is approximately a zero-sum game:
the more consumption for any one group — children,
workers, retirees — means less for the others.
The basic compact can be altered in many ways, the
most important of which affects future generations. In
basic terms, if the current working population not only
pays for their children and supports their parents, but
Crippen and Barnato
also saves a portion of their income, then economic
growth can be accelerated and future economies will
be larger, thus making it easier to assist future depen-
dent populations. Savings add to the capital available,
making it easier (and cheaper) to provide investment
that increases national output. It is important to note
that it is national savings that counts — the total of
individuals, business, government, non-profits — and
borrowing by any sector reduces the positive effect of
savings by others.
Similarly, if borrowing is
used to fund today’s consump-
tion of goods and services,

future spending and saving will
be reduced. In the case of gov-
ernment borrowing, especially
by the federal government, it
is possible to push the costs of
debt well into the future.
For example, current inter-
est costs on the federal debt
are nearly $200 billion. With
the expected deficits over the
next decade, interest is pro-
jected to grow to $800 billion
— nearly as much as the total
for Medicare in 2020. That
means federal spending will
need to be cut, taxes increased,
or additional debt incurred to
cover just the interest on our
debt.
As we continue to increase
debt, future generations will
have less to spend and invest. To the extent the spend-
ing and borrowing of government is needed/used to
fund health care, the country is pushing the cost of
today’s health care onto future citizens. Under cur-
rent policies, the present cohort of children will be
expected to pay not only for their own children and
parents, but also for past generations as well, breaking
the basic intergenerational compact.
Figure 1
Life-Cycle Income and Consumption in the United States

Figure 2
Per Capita Spending on Children and the Elderly in the United
States
Source: Issacs, 2009
S Y M P O S I U M
Health Spending across Populations
A substantial part of cross-generational
transfers, especially in developed countries,
are attributable to spending for education
and health care. Figure 2 shows estimates of
resources used in the United States in a typi-
cal year by or for a “child” (up to age 18) and
“elder” (over 65).
Although there is a large disparity between
the resources expended on the two groups,
there is nothing inherently wrong, unethical,
or amoral about the greater spending for our
elders. Rather, it is a reflection of our collec-
tive decisions on the amount of resources we
chose to reallocate largely from the working
population to those who are on both ends of
life.
As a society, we provide education for our
children, and income and health care for the
elderly. Unfortunately, the tradeoff between
the two is not often analyzed.1 With fixed
resources, at any point in time the more we

spend on one, the less we have to spend on the other —
or the less workers have to consume. Currently in the
U.S., most of the public transfers to the elderly occur
at the national level, through the federal budget, while
many of the decisions on education spending are made
at the state and local levels.
One exception to this general division of responsi-
bility is Medicaid, which provides health care to parts
of the lower-income population, including the dis-
abled and elderly, and is funded by both the federal
(55%) and state (45%) governments. Medicaid allows
states some discretion as to whom they cover and how
they deliver services, but dictates a minimum level of
benefits. An expansion of the Medicaid program, by
an additional 15 million people, is one of the ways last
year’s health reform legislation provides coverage to
the uninsured.
This program, along with health spending for pub-
lic employees and retirees, is putting increasing pres-
sure on other state spending, particularly funding for
education, which the states in turn are reducing and
pushing down to the local level. While localities do
not have to fund Medicaid, they do have health costs
for employees and retirees putting similar pressure on
education and other local responsibilities.
Before reaching any inherently subjective conclu-
sions, such as how much is “enough,” it is important
to understand more about what health spending buys,
and for whom.
Figure 3 illustrates a perhaps obvious point that
hospitals and physicians make up the majority of
costs, and when lab work and other related services

are added, nearly 60% of the total. What may be more
surprising is how relatively little is spent on some sec-
tors, such as prescriptions and public health.
Over time there has been a dramatic shift away from
private financing of health care (insurance and out-
of-pocket) to financing by and through government.
Last year private insurance covered only about 1/3
of all spending, and out-of-pocket costs to patients
amounted to 12% of the total.
Most of this spending in any given year is incurred
on behalf of a relatively small proportion of the popu-
lation. Standard rules-of-thumb — 5% of the popula-
tion spend 50% of the costs; 20% of the population
make up 80% of the costs — suggest how concentrated
health care needs are. In Figure 4, these “expensive”
patients appear in the right-hand side of the graph.
Included here are episodic expenses for maternity, a
case of pneumonia, or trauma from an accident. Yet
the vast majority, 75%, of spending in this right-hand
side of the graph is for patients with chronic disease.
High Cost of Health Care Is Due to
Chronic Disease, Not the End of Life
Advances in the prevention and treatment of infec-
tious disease, the widespread adoption of water treat-
ment in developed countries, the ability to diagnose
and treat chronic illness, and the decline in smoking,
have all contributed to an increase in the number of
years we can expect to live.
As we live longer, however, we tend to develop
chronic disease, and often several chronic illnesses
concurrently. For example, the “average” Medicare

Figure 3
The Composition of Health Care Spending in 2009
Crippen and Barnato
patient in the top quarter of spending has five chronic
conditions, sees 12 separate physicians over the course
of a year, fills 50 prescriptions for various drugs, and
is hospitalized at least once. For some, this treatment
occurs at the end of their lives. About 27% of all Medi-
care spending is used each year for people who die, a
proportion that has been stable over several decades.2
The stability of this concentration suggests that what-
ever is affecting overall cost increases is affecting dece-
dents and survivors alike. It is not increases in end-
of-life spending that is driving up the cost of health
care, but overall health care costs propelled by the
increase in chronic disease, technology to detect and
treat it, and in the costs of treating patients with mul-
tiple chronic conditions.3 In Medicare, most expensive
patients live on for several years, and incur high costs
such as repeat hospitalizations in subsequent years.
It is not just the elderly who develop chronic dis-
ease. Increasingly, children are developing diabetes
and associated conditions, often due to obesity. More
asthma is being diagnosed. Patients with addiction
and behavioral health issues, including depression,
often have chronic illnesses and are expensive to

treat.
In fact, behavioral health issues are prevalent
enough throughout all age groups that it will be dif-
ficult to control costs without adequately addressing
behavioral health as a co-morbidity. Figure 5 attempts
to separate spending for typical chronic conditions by
behavioral health diagnoses. This Medicaid popula-
tion (which is undoubtedly more prone to issues of
mental health and addiction), suggests the number of
hospitalizations in a year may be 3-6 times more for
patients with behavioral health complications, result-
ing in as much as a $30,000 difference in the annual
cost of treatment.
Ultimately it is the complexity of treatment of multi-
ple diseases, and our inability to treat complex patients
satisfactorily with current practices, that is driving
health spending on chronic disease.
Dr. Gerard Anderson, updating some of
his previous work on the nature of chronic
disease in America, recently concluded:
Unfortunately, while our health care
needs have evolved, often the health
care system has not. It remains an
amalgam of past efforts to treat infec-
tious diseases and acute illnesses.
It does not focus on today’s current
and growing problem — increasing
numbers of people with chronic condi-
tions, especially those with multiple
chronic conditions…. Many people

with chronic conditions have multiple
chronic conditions and this neces-
sitates multiple caregivers. The cur-
rent system provides few incentives
for physicians and other caregivers to
coordinate care across providers and
service settings. We know that many
people with chronic conditions report
receiving conflicting advice from differ-
ent physicians and differing diagnoses
for the same set of symptoms. Drug-to-
drug interactions are common, some-
Figure 4
Per Capita Health Spending as a Percent of the Population
It is not increases in end-of-life spending that is driving up
the cost of health care, but overall health care costs propelled
by the increase
in chronic disease, technology to detect and treat it, and in the
costs of treating
patients with multiple chronic conditions.
S Y M P O S I U M
times resulting in unnecessary hospi-
talizations and even death. People with
chronic conditions are getting services,
but those services are not necessarily
coordinated with one another, and they
are not always the services needed to

maintain health and functioning.4
As exemplified by the expensive Medicare patients
cited above, the dozen doctors delivering care are an
assortment of largely specialists who are trained to
treat specific diseases. The coordination of care, where
it occurs often falls to general practitioners and inter-
nists, who are paid less and who often do not have
even the basic information from all the providers. Bet-
ter health information systems will help this task, but
it is far from sufficient to ensure success.
More important is the development of more knowl-
edge about how to treat multiple conditions in one
patient. Dr. Cynthia Boyd of Johns Hopkins Univer-
sity5 compared the recommended treatment for an
elderly woman with five typical conditions for a female
of her age: diabetes, hypertension, arthritis, osteopo-
rosis, and difficulty in breathing (COPD). Applying the
best-evidence medicine for each of the five conditions
resulted in a large pharmacy load (12 medications, 20
pills a day), contradictory exercise regimes, and con-
flicting dietary advice. Dr. Boyd concluded:
Although CPGs (Clinical Practice Guidelines)
provide detailed guidance for managing single
diseases, they fail to address the needs of older
patients with complex co-morbid illness…. It is evi-
dent that CPGs, designed largely by specialty-dom-
inated committees for managing single diseases,
provide clinicians little guidance about caring for
older patients with multiple chronic diseases.6
The Department of Health and Human Services has
begun to recognize this challenge and issued a report
in December 2010, entitled, New Strategic Framework

on Multiple Chronic Conditions.7
Health Spending across Generations
Thus far we have considered how current spending
for health care could crowd-out spending for other
needs across the country, looking particularly at allo-
cations for children. Again, it is not self-evident that
the current allocation between the young, workers,
and retirees is somehow wrong or unethical. Rather,
it is demonstrative that the high cost of health care, if
it could be reduced, could free up resources to be used
for the young, to reduce public deficits, or returned to
taxpayers.
It is possible to examine how the current distribu-
tion of resources will be affected in the future. Current
deficits, to the extent they continue, will push more
of the funding for today’s federal programs into the
Figure 5
Hospitalizations for a Medicaid Population, by Disease and
Behavioral Health Status
Source: Center for Health Care Strategies
Crippen and Barnato
future, leaving interest and principal payments for
generations to come.
Figure 6 depicts the finances of the federal gov-
ernment over a long period, wherein total revenues

amounted to about 18% of the economy (GDP) and
spending around 20% of GDP. In the last two years,
revenues have fallen and spending has increased by
historic amounts, resulting in deficits of 9-10% of
GDP.
Perhaps more important, the outlook for the future,
while improved, is the continuation of large deficits.
Revenues do increase over time (this graph assumes
the Bush-era tax cuts are not made permanent) and
spending declines somewhat before the impending
retirement of the baby boom generation begins to
push retirement and health spending up rapidly.
In perhaps more understandable terms, the federal
government currently spends the equivalent of roughly
$30,000 per household in the United States, collects
$20,000, and borrows $10,000. The $10,000 in new
debt will be added to the $90,000 per household in
previous borrowing. Interest payments on the debt
amount to about $2,000 of the $30,000 in spend-
ing. With the continued deficits in the current budget,
interest payments will rise to $8,000 per household
by 2020, just a few years from now. These numbers
all pale in comparison to the approximately $750,000
per household in unfunded future promises — prom-
ises made mostly for pensions and health care.
The $10,000 for each household in new debt this
year covers the deficit for the entire federal budget,
not just spending for health care. In that sense, the
borrowing could be attributed to any, or all, federal
programs, including the wars in the Middle East.
However, the ever-increasing health care costs in
the budget, propelled by the retirement of the baby-
boomers, will require very significant tax increases,

cuts in other programs, or continued unprecedented
borrowing.
Figure 7 suggests that these three federal programs
for retirees and disabled will, in less than 20 years,
require funding levels near the entirety of what we
currently collect in federal revenues. Tax increases to
cover these programs (while maintaining the rest of
the budget) would amount to 4-5 times the size of the
Bush-era tax cuts. These additional taxes would have
to come largely from workers, rich and poor alike, to
cover the gap. Borrowing to fill the hole would require
yearly debt increases in the 100s of billions of dollars
— amounts that our creditors around the world may,
at some point, be reluctant to provide.
Without conjecturing how this might all work out,
it is fairly clear that increasing health care spending,
particularly for the elderly baby boomers, on a scale
promised under current law will likely result in at least
some increased borrowing (along with tax increases
and spending cuts in other programs). To the extent it
does, future generations will be paying for the boom-
Figure 6
Federal Revenues and Spending as a Percent of GDP
S Y M P O S I U M
ers’ retirement, not just the boomers’ children as the
basic social compact would suggest.

State and local governments, already under extreme
financial pressures, will fare no better. As noted earlier,
some states are approaching the time when spend-
ing on health care will overtake that for education.
In the future, sometime before mid-century, health
care spending will exceed all other state spending.
The current disparity between young and old will be
greatly exacerbated and for those states who manage
to borrow, the onus on future generations will be even
larger.
(A Word about) Health Reform
With the passage of health reform legislation last year,
there is the prospect of change in the patterns iden-
tified earlier. The primary objective of the legislation
is to expand financing and coverage of health care for
previously uninsured citizens.
On that score, if the legislation is successfully imple-
mented, as many as 30 million more Americans will
have some form of health coverage starting in 2014.
It should not be surprising that this coverage will
come at a substantial cost since giving more people
more health care is the intent. The
short-term debate is over whether tax
increases and spending cuts in the leg-
islation will be enough to cover these
increased costs.
The longer-term issue, however, is
whether other changes — in payment
systems, additional research on what
works, and more decision making
outside normal congressional pro-
cesses — will help hold down future

cost increases. Skeptics abound and
even proponents admit it will be
years before we know how effective
these changes can be. It is particularly
uncertain that any of the changes will
alter health care delivery, and there-
fore costs, for the 75% of spending
devoted to chronic care. Suffice it to
say, rapidly growing health care costs
will be a major concern and public
issue for at least the next decade, and
likely much longer.
One case study is the State of Massa-
chusetts. In 2006, Massachusetts enacted
sweeping health care reform similar to that
passed by the Congress earlier this year. In
many fundamental ways, Massachusetts
was a model for the federal legislation. The
reforms are also similar in that Massachu-
setts was successful in providing coverage
for many more of its uninsured citizens. Costs, how-
ever, have gone up considerably — much more than
anticipated when the legislation passed — to the point
where total for health care spending is 40% of the
entire budget, almost twice that for education.
Conclusion
A large disparity exists between resources consumed
by today’s children relative to their retired counter-
parts. A considerable amount of the difference can be
attributed to spending on health care. To the extent a
question of ethics arises, it may come down to whether
we are spending “enough” on our children to support

them in their youth and prepare them for the future.
This disparity will grow over the foreseeable future
and, based on current law and experience, cause more
debt to be accumulated for upcoming generations to
pay. We are financing some of today’s spending on
health care by effectively borrowing from future gen-
erations. We will likely do so in ever-larger amounts in
the future. The ethics of foisting off the payment for
our health consumption on unborn citizens provokes
a sharper dilemma.
Figure 7
Spending for Social Security, Medicare and Medicaid as a
Percent
of GDP
Unless we change the practice of medicine
and reduce future costs, and explicitly address
the ethical dilemmas we face, there may come
a time when our kids simply cannot afford us.
Crippen and Barnato
In both cases — allocation of resources across our
current population and the practice of borrowing
from future generations to fund current consumption
— health care plays a major role. While end-of-life
spending is significant, and any reduction would help
ease both cases, it is the ongoing health care of citizens
with multiple chronic conditions that poses the great-
est challenge in resolving these dilemmas, for current

and future generations.
The good news is that it is possible to give patients
with chronic disease better health, and thereby reduce
costs, by (among others): emphasizing, and paying for,
coordination of care; recognizing the role behavioral
health plays in physical health; and increasing patient
compliance with treatment protocols. In addition, a
national research agenda should be developed and
funded to better understand the interactions of chronic
conditions and their treatment, including pharmacy,
and the role of patients in developing and implement-
ing disease management. Unless we change the prac-
tice of medicine and reduce future costs, and explicitly
address the ethical dilemmas we face, there may come
a time when our kids simply cannot afford us.
FIGURE LEGENDS
Figure 1. Life-Cycle Income and Consumption for
the United States Over the course of a lifetime, there
are distinct periods where we consume more than we
produce (as children and retirees) and periods where
we produce more than we consume (as working-age
adults). The patterns vary by country, economy, and
culture, and are reflective of the public programs in
place to redistribute income from current workers to
those too young or old to work.
Figure 2. Per Capita Spending on Children and the
Elderly (by Type of Spending in the United States) In
the U.S., we provide much more support to our indi-
vidual retirees than we do our children. The single
most important reason for the difference is the dispar-
ity of spending on health care.
Figure 3. The Composition of Health Care Spend-

ing in 2009 National surveys allow estimates of the
breakdown of health care dollars among the various
providers of care, and other systemic costs such as
public health.
Figure 4. Per Capita Health Spending as a Percent of
the Population There is not much validity to citing an
“average” patient. While there are certainly people in
the middle, there are essentially two groups of patients:
those who don’t spend much in any given year, and
those who spend a lot. The general rules of thumb are:
5% of the population drives 50% of total spending in a
year; 20% of the population drive 80% of total costs.
The mirror image is important for policy as well — 80%
of the population spends only 20% of the total costs.
Figure 5. Hospitalization for a Medicaid Population,
by Disease and Behavioral Health Status Health care
costs are often characterized as the expenses for treating
physical maladies. However, those physical health costs,
especially those for chronic care, are often compounded
by behavioral health problems, such as depression or
addiction. For this population it is not the cost of dying
that drives costs as much as the cost of living.
Figure 6. Federal Revenue and Spending as a Per-
cent of GDP Figure 6 illustrates a number of points,
but for these purposes perhaps the most important
is that even after post-recession revenues recover (to
nearly historic highs) and stimulus spending disap-
pears, there is a substantial and growing gap between
the two, resulting in large deficits that continue for
decades.
Figure 7. Spending for Social Security, Medicare and

Medicaid as a Percent of GDP These three programs,
driven by retirement of the baby boomers and the
ever-increasing cost of health care, will require nearly
all the federal revenues collected in 2030.
References
1. J. B. Isaacs, Public Spending on Children and the Elderly
From
a Life-Cycle Perspective, Brookings Institution, Washington,
D.C., November 2009.
2. C. Hogan, J. Lunney, J. Gabel, and J. Lynn, “Medicare Ben-
eficiaries’ Costs of Care in the Last Year of Life,” Health
Affairs
20, no. 4 (July 2001): 188-195.
3. A. E. Barnato, M. B. Mcclellan, C. R. Kagay, and A. M.
Garber,
“Trends in Inpatient Treatment Intensity among Medicare
Benefi-
ciaries at the End of Life,” Health Services Research 39, no. 2
(April 2004): 363-376.
4. G. Anderson, Chronic Conditions: Making the Case for
Ongo-
ing Care, Johns Hopkins University, November 2007, at 5-6.
5. C. M. Boyd, J. Darer, C. Boult, L. P. Fried, L. Boult, and A.
W.
Wu, “Clinical Practice Guidelines and Quality of Care for Older
Patients with Multiple Comorbid Diseases,” JAMA 294, no. 6
(2005): 716-724.
6. Id., at 720.
7. Department of Health and Human Services, New Strategic

Framework on Multiple Chronic Conditions, December 2010.
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Pavlish, Carol, PhD, RN, FAAN;Brown-Saltzman, Katherine,
MA, RN;Hersh, Mary, MSN, RN, CHPN, FPCN;...
Journal of Nursing Scholarship; Dec 2011; 43, 4; ProQuest
pg. 385

International Journal of Nursing Studies 47 (2010) 635–650
Review
Nurses’ ethical reasoning and behaviour: A literature review
Sabine Goethals a,*, Chris Gastmans b, Bernadette Dierckx de
Casterlé c
a Catholic University College Ghent, Department of Nursing,
Hospitaalstraat 23, 9100 Sint-Niklaas, Belgium
b Centre for Biomedical Ethics and Law, Faculty of Medicine,
Catholic University Leuven, Belgium
c Centre of Health Services and Nursing Research, Catholic
University Leuven, Belgium
A R T I C L E I N F O
Article history:
Received 16 July 2009
Received in revised form 4 November 2009
Accepted 18 December 2009
Keywords:

Ethical behaviour
Ethical decision making
Ethical reasoning
Ethics
Nursing
Literature review
A B S T R A C T
Background: Today’s healthcare system requires that nurses
have strong medical–
technical competences and the ability to focus on the ethical
dimension of care. For
nurses, coping with the ethical dimension of care in practise is
very difficult. Often nurses
cannot act according to their own personal values and norms.
This generates internal
moral distress, which has a negative impact on both nurses and
patients.
Objectives: The objective of this review is a thorough analysis
of the literature about
nurses’ ethical practise particularly with regard to their
processes of ethical reasoning and
decision making and implementation of those decisions in

practise.
Design: We conducted an extensive search of the electronic
databases Medline, Embase,
Cinahl, and PsycInfo for papers published between January
1988 and September 2008. A
broad range of search keywords was used. The 39 selected
articles had a quantitative,
qualitative, or mixed-method design.
Findings: Despite the conceptual difficulties that the literature
on the ethical practise of
nurses suffers, in this review we understand nurses’ ethical
practise a complex process of
reasoning, decision making, and implementation of the decision
in practise. The process of
decision making is more than a pure cognitive process; it is
influenced by personal and
contextual factors. The difficulties nurses encounter in their
ethical conduct are linked to
their difficult work environment. As a result, nurses often
capitulate to the decisions made
by others, which results in a conformist way of acting and less
individually adapted care.
Conclusions: This review provides us with a more nuanced
understanding of the way nurses

reason and act in ethically difficult situations than emerged
previously. If we want to support
nurses in their ethical care and if we want to help them to
change their conformist practises,
more research is needed. Especially needed are in-depth
qualitative studies that explore the
experiences of nurses. Such studies could help us better
understand not only how nurses
reason and behave in practise but also the relationship between
these two processes.
� 2010 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
What is already known about this topic?
� T
00
do
he ethical dimension of care is difficult to realise in the
complex and stressful work environment that charac-
terizes today’s nursing practise.
� N
urses are regularly confronted with ethical decisions

that others make and that are in conflict with their own
* Corresponding author. Tel.: +32 37808905; fax: +32
37663462.
E-mail address: [email protected] (S. Goethals).
20-7489/$ – see front matter � 2010 Elsevier Ltd. All rights
reserved.
i:10.1016/j.ijnurstu.2009.12.010
personal values and norms.
� N
urses who cannot sufficiently integrate their own
values and norms into their daily practise may experi-
ence moral distress. Moral distress results in less
appropriate patient care and in nurses’ burnout.
What this paper adds
� T
his review provides a more nuanced understanding of the
way nurses reason and act in ethically difficult situations.
�
mailto:[email protected]
http://www.sciencedirect.com/science/journal/00207489
http://dx.doi.org/10.1016/j.ijnurstu.2009.12.010
S. Goethals et al. / International Journal of Nursing Studies 47
(2010) 635–650636
The process of decision making is more than a pure
cognitive process; it is a difficult and complex process

influenced by personal and contextual factors.
� T
he difficulties nurses encounter in their ethical practise
are linked to their difficult work environment.
1. Introduction
Today, nurses’ practise is characterized by a strong
emphasis on high technological interventions and financial
limitations, and is dominated by economic values (Dean,
1998; Spitzer, 1998; Milisen et al., 2006). Nurses are
therefore confronted with complex care situations in
which they are expected to autonomously make decisions
in delivering good care to patients and to do so within the
confines of strict deadlines. ‘Good care’ is oriented towards
the promotion of the patient’s well-being in its entirety,
i.e., considering patients’ physical as well as psychological,
relational, social, moral, and spiritual well-being and so
can be considered as a moral practise (Gastmans et al.,
1998).
The ethical dimension of care cannot be restricted to
specific ethical dilemmas in the context of the beginning
and end of life. On the contrary, the ethical dimension of
care is an essential part of nursing practise (Bishop and
Scudder, 1990). Nurses make daily decisions that are
ethically informed. Examples can be found in how they
deal with intimacy and privacy (Mattiasson and Hemberg,
1998) and the use of physical restraints in their care for the
elderly (Gastmans and Milisen, 2006). Acting responsibly
in these and comparable situations requires not only
medical/technical competency but also the ability to

reflect critically about ethical dilemmas and the ability
to surpass the mere implementation of previously defined
rules (Bolmsjö et al., 2006).
Even though ethics is a constitutive element in current
nursing education, research reveals that nurses face
considerable difficulties when they have to implement
the ethical dimensions of care in daily professional practise
(Woods, 2005). Siebens et al. (2006) reported that nurses
working in a complex work environment give priority to
medical/technical interventions; establishing caring rela-
tionships with their patients is of secondary importance. It
is worrisome that nurses complain that it is impossible for
them to practise according to their own ethical values or to
voice ethical issues within the team. Furthermore,
although nurses are regularly confronted with healthcare
decisions that they perceive as morally wrong, they are
expected to execute those decisions (Gutteriez, 2005).
Nurses may feel that their self-image and integrity is
threatened, if they have to comply with unwritten rules
and routines and if they are unable to act according to their
professional ideals because of practical circumstances
(Sorlie et al., 2003; Torjuul and Sorlie, 2006). Regularly
confronting such situations can lead to moral distress
(Kälvemark et al., 2004; Gutteriez, 2005; Torjuul and
Sorlie, 2006). According to Jameton (1984), nurses
experience moral distress when they judge a particular
decision to be ethically correct but are unable to execute it
because of situational factors. Nurses most commonly
respond to moral distress by being less involved with
patients and family members and by providing less
personalized care (Gutteriez, 2005). As for nurses them-
selves, moral distress may lead to decreased job satisfac-
tion, increased staff turnover, health problems, and
burnout, with nurses eventually leaving the profession
(Gutteriez, 2005; Torjuul and Sorlie, 2006). Where Schluter

et al. (2008) report a (developing) relationship between
moral distress of nurses and the organization’s ethical
climate, Pauly et al. (2009) confirm this relationship, which
would be negatively correlated.
Given the significant consequences of moral distress for
nurses as well as for patients, it is essential to identify and
to fully understand what is currently known in literature
about nurses’ ethical practise. This insight may help us
provide guidance to nurses that can support them in the
ethical dimension of care.
2. Review
2.1. Aim
The objective of this review was to thoroughly examine
the literature about nurses’ ethical reasoning process and
nurses’ ethical behaviour. Ethical practise includes the
reasoning process, the associated decisions, and the actual
implementation of the ethical decisions (Dierckx de
Casterlé et al., 1997). Ethical reasoning involves the
cognitive process of reasoning, which leads to moral
decision making (Ketefian, 1989; Omery, 1989). We view
ethical behaviour as putting an ethical decision into
practise (Dierckx de Casterlé et al., 1997).
In this review, we specifically address the following
research questions: (1) How do nurses reason when they
are faced with an ethical decision? (2) How do nurses
implement their ethical decisions in practise?
2.2. Review methodology
This review was conducted by following the guidelines
of the United Kingdom Centre for Reviews and Dissemina-

tion Guidelines on Systematic Reviews (Centre for Reviews
and Dissemination, 2001). Articles were read, and relevant
data were isolated, compared, and related. After consulta-
tion with the other researchers (BD, CG), concepts and
themes were identified (Dixon-Woods et al., 2006).
2.3. Search strategy
We conducted an extensive search in the databases
Medline, Embase, Cinahl, and PsycInfo for papers pub-
lished between January 1988 and September 2008 on
nurses’ ethical practise. This review follows the review of
Ketefian (1989), who systematically searched the litera-
ture from 1983 to 1987. The following keywords were
used: ‘ethical reasoning’, ‘ethical decision making’, ‘moral
reasoning’, ‘ethical practise’, ‘ethical action’, ‘ethical
behavio(u)r’, ‘moral behavio(u)r’, ‘moral judgment’. Each
of these terms was combined with the wildcard term
‘nurs*’ and ‘research’.
This resulted in 6889 results. Titles and abstracts were
screened, and studies were included if they met the
(2010) 635–650 637
following criteria: (1) empirical research published in
Dutch, French, English, and German; and (2) research that
dealt with the ethical reasoning and/or ethical behaviour of
nurses. Publications were excluded if (1) the article
concerned only student nurses, and (2) the studies were
reviews or (3) doctoral dissertations. Reference lists of all
articles were examined for additional publications not
previously identified (Centre for Reviews and Dissemina-
tion, 2001). Manual search of bibliographies of relevant

articles was done and ethics experts (BD, CG) suggested
other pertinent articles. These procedures added no
articles. Our search procedure resulted in 39 papers which
we examined critically.
2.4. Search outcome
The search strategy yielded 39 appropriate publications
that described 38 separate studies (Tables 1–3). The
articles from Lützen and Nordin (1993b, 1994) were
derived from the same study; therefore, we considered
these articles together as representing one study. Thirteen
studies used a quantitative design (Table 1); eighteen used
a qualitative design (Table 2); and seven used a mixed
method (Table 3). Ethical reasoning was studied in 24
studies, most of which were qualitative studies. Ethical
behaviour was studied in ten studies, in which researchers
used both quantitative and qualitative research designs.
Four studies described both ethical reasoning and ethical
behaviour processes (Carpenter, 1991; Vogel Smith, 1996;
Dierckx de Casterlé et al., 1997, 2008). Only one study
examined the relationship between ethical reasoning and
the implementation of ethical decisions in practise
(Dierckx de Casterlé et al., 1997).
The studies were conducted in ten different countries:
USA (n = 14); Sweden (n = 9); Canada (n = 4); Australia
(n = 2); and Belgium, Denmark, Greece, Korea, Mexico, and
South Africa (n = 1 for each country). Three studies
reported results from internationally conducted research
(Davidson et al., 1990; Norberg et al., 1994; Dierckx de
Casterlé et al., 2008).
Most research settings consisted of a combination of
several acute and/or chronic settings. In 24 studies, the
sample consisted of only nurses. The remaining studies

consisted of nurses and/or nursing students and/or doctors
and/or other healthcare workers. The combined research
population consisted of about 4100 nurses, mainly women,
between 20 and 65 years old, and with a nursing
experience ranging from <1 year to 39 years.
2.5. Methodological features
The methodological features of the included studies are
summarized in Tables 1–3. Barring one study (Kim et al.,
2007), all quantitative studies implemented a descriptive,
correlational or comparative design. In the quantitative
studies, the sample sizes varied from 63 to 1592 nurses.
Response rates, when mentioned, varied from 20% to 84%
(Table 1). The sampling methods were very diverse:
random sampling (Kuhse et al., 1997; Dodd et al., 2004);
stratified random sampling (Erlen and Sereika, 1997);
purpose sampling (Dierckx de Casterlé et al., 1997;
Penticuff and Walden, 2000); convenience sampling
(Corley and Selig, 1994; Kyriacos, 1995; Raines, 2000);
and randomized convenience sampling (Ham, 2004). In
some studies, the sampling method was not mentioned
(Garritson, 1988; Elder et al., 2003; Kim et al., 2007).
In the qualitative studies, the sample sizes varied from 9
to 169 nurses (Table 2). In half of these studies, nurses were
purposefully selected using specific criteria, such as
‘experienced and good’ (Jansson and Norberg, 1989,
1992; Davidson et al., 1990; Aström et al., 1993, 1995;
Norberg et al., 1994); ‘competent and reflective’ (Lützen
and Nordin, 1993a, 1994); ‘recommended by peers and
supervisors’ (Lützen and Nordin, 1993b); and ‘thoughtful
about ethical questions’ (Oberle and Hughes, 2001).
In the mixed-method studies, the sample sizes varied
from 20 to 149 nurses (Table 3). In the study of Norberg et

al. (1994), nurses were also selected using the criterion
‘experienced and good’. In three other studies, the
sampling method was convenience sampling (Chally,
1995; Mattiasson and Andersson, 1995; Monterosso et
al., 2005).
Many of the studies lacked clear conceptualisation and
operationalization of the terms ‘ethical reasoning’ and
‘ethical behaviour’, leading to the development and use of
customised definitions. Some studies even failed to define
the concepts of ‘ethical reasoning’ and ‘ethical behaviour’.
Especially in studies that used quantitative and mixed
methods, various theoretical frames and definitions were
used to study ethical reasoning and ethical behaviour
processes. Theories that were frequently referred to were
the moral development theory by Kohlberg (1981), the
four principles of biomedical ethics by Beauchamp and
Childress (1979), the justice-care perspective by Gilligan
(1982), and deontological and teleological approaches.
The use of established measurement instruments, like
the Nursing Dilemma Test (Crisham, 1981) and the
Judgment about Nursing Dilemmas (Ketefian, 1981) was
very limited. Most researchers developed their own
instruments to measure ethical reasoning and behaviour,
using vignettes, dilemmas, and/or questionnaires that
measured variables considered to be connected with
ethical reasoning and/or ethical behaviour.
In some of the qualitative studies, nurses presented
ethically difficult situations and then described how they
subsequently handled these situations in practise (Erlen
and Frost, 1991; Grundstein-Amado, 1992; Uden et al.,
1992; Aström et al., 1993, 1995; Lützen and Nordin,
1993a,b, 1994; Chally, 1995; Oberle and Hughes, 2001;
Rodney et al., 2002; Tsaloglidou et al., 2007). In sixteen

qualitative studies, respondents were interviewed. Two
studies used focus groups. Only two studies combined two
methods to obtain data (Rodney et al., 2002; Tsaloglidou et
al., 2007). Many of the studies used well-known metho-
dological approaches like the grounded theory (n = 4),
phenomenology (n = 4), constructivist methodology
(n = 2), and narrative theory (n = 1).
2.6. Quality appraisal
One researcher (SG) assessed the included publications
using the assessment sheets prepared and tested by
Table 1
Quantitative studies included in the literature review.
Author(s) Country Aim(s) of the study Design- sample Data
collection Data analysis
Care setting Response rate (RR)
Garritson (1988) USA
29 psychiatric inpatient
units in private, county,
veterans administration
university hospitals
To investigate nurses’ ethical

decision-making patterns
Quantitative
177 registered nurses (RNs)
RR: 20–4%
Questionnaires presented to
nurses during staff meetings,
distributed to nurses’ mailboxes
Questionnaire included: staff
demographic characteristics,
case vignettes, nursing
philosophy statement
Frequency data
Bowker Test of
Symmetry
Corley and
Selig (1994)
USA
Federal teaching hospital

(850 beds)—all CCUs:
medical, surgical, coronary,
haemodialysis, emergency
admitting
To examine how often nurses
use principled thinking to
decide on actions in specific
ethical situations
Quantitative exploratory
91 RNs
RR: 82% (n = 75)
Questionnaire: Nursing
Dilemma Test (NDT)
(Crisham, 1981)
Six client care dilemmas
considering the following:
nurses’ principled thinking,
practical considerations,

and other issues considered
in making a decision
Frequency data
t-test
Pearson product
moment
correlation
Kyriacos (1995) South Africa
Convenience sample
of nurses following
an ethical workshop
To explore nurses’ stage of
thinking in moral judgment
development
109 nurses
RR: 63% (n = 69)
Questionnaire: completing
the questionnaire on a

one-day nursing ethics
workshop NDT (Crisham, 1981)
Six client care dilemmas—considering
nurses’ principled thinking
Frequency data
Dierckx de Casterlé
et al. (1997)
Belgium
14 Flemish schools
of nursing
University students
Expert nurses
To explore nursing students’
ethical behaviour in five
nursing dilemmas
Quantitative descriptive
correlational
2634 nursing students

(technical–professional)
176 university students
59 expert nurses
Questionnaire: Ethical Behaviour
Test (EBT) based on DIT (Rest, 1976)
and NDT (Crisham, 1981) developed
by Dierckx de Casterlé (1993)
Five stories depicting nurses in daily
ethical dilemmas were used to
assess the subjects’ perceptions
of the nursing dilemma and the way
in which they would reason and
act in that situation
Two-way analysis of
variance
Bonferroni method
Multivariate analysis
(MANOVA)

Erlen and
Sereika (1997)
USA
2 tertiary care
university-affiliated
hospitals
16 ICUs
To measure ethical decision
making and stress
To examine the relationship
of selected nurse characteristics
with aspects of ethical decision
making and stress
To examine the relationship
between ethical decision-making
and stress in ICU nurses
correlational

Stratified random
sample—proportional
allocation
80 nurses
RR: 78.8% (n = 63)
Questionnaires mailed to
interested nurses
NEDM-ICU: Nursing Ethical Decision
Making—ICU included: NEDM-ICU
part I, WPR: workplace restrictions,
RT: risk taking. NEDM-ICU part II,
NA: nurse autonomy, PR: patient
rights, RTR: rejection traditional
role, HPSI: Health Professional
Stress Inventory
30 general stressful
situations—identification of how
stressful nurses perceive a

particular situation
Pearson product
moment correlation
Student’s t-test
One-way analysis
of variance (ANOVA)
Tukey’s pairwise
multiple comparison
Mann–Whitney U test
Spearman’s rank order
correlation
S
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Kuhse et al. (1997) USA
Victorian and New
South Wales Medical

Boards
Australian Nursing
Federation
To discover whether gender or
occupation affected the approach
(partialist or impartialist) that
participants took in response to
various moral dilemmas
correlational
Random sample
400 doctors from Victoria,
200 doctors and 400 nurses
form New South Wales
RR: 30.5% (n = 122 nurses)
Questionnaire mailed to a
randomly selected sample
of nurses and doctors

Questionnaire included:
4 moral dilemmas involving
combinations of (healthcare)
professional, non-professional,
life-threatening, and
non-life-threatening situations
Lambda measures
Penticuff and
Walden (2000)
USA
4 obstetrics units
and 4 neonatal
ICU from 5 major
hospitals
To explore the relative contributions
of practical environment
characteristics and nurses’ personal
and professional characteristics

on the willingness of perinatal nurses
to be involved in activities used to
resolve clinical ethical dilemmas
correlational
Purpose sample
200 nurses
RR: 64% (n = 127)
Questionnaires: personal invitation
to nurses—nurses who agreed
received questionnaires
Demographic Data Sheet, PVQ:
Perinatal Value Questionnaire,
NEIS: Nursing Ethical Involvement
Scale
Multiple
regression analysis

Raines (2000) USA
Oncology nurses
To determine the relationship
between moral reasoning,
coping style, and ethics stress
correlational—survey
Convenience sample
795 nurses
RR: 29% (n = 229)
Questionnaires to oncology nurses
members of Oncology Nursing
Society (nationwide), a professional
nursing organization
Demographic Data Sheet, MRQ:
Moral Reasoning Questionnaire,
WCI: ways of coping inventory, ESS:

Ethical Stress Scale, EIS: Ethics
Inventory Instrument
Descriptive statistics
Multiple regression
analysis
Analysis of variance
(ANOVA)
Elder et al. (2003) Australia-Queensland
Hospital environment
To explore differences in the
ethical attitudes of medical
students and nurses
Voluntary participation
125 medical students
67 nurses
Questionnaire was completed by
nurses during a seminar

Questionnaire containing 23 vignettes
followed by four alternative responses
t-test
(ANOVA)
Dodd et al. (2004) USA, New York
3 urban hospitals
A non-profit hospital
(903 beds)
A university hospital
(600 beds)
A rehabilitation hospital
(396 beds)
To explore the extent to
which nurses engage in
ethical activism and
ethical assertiveness

correlational
Random sample
165 nurses from 3 hospitals
RR from 3 hospitals: 26–41%
Postal self-administered 72-item
questionnaire
Ethical activism
Ethical assertiveness
(ANOVA)
Bonferroni post
hoc analysis
t-test
Multiple regression
analysis
Ham (2004) USA
4 Midwestern states
To study the effects of

environmental influences
and previous ethical
decision-making experiences
on nurses’ moral reasoning
Randomized convenience
sample
500 RN
RR RN: 24% (n = 120)
Questionnaire mailed to randomly
selected nurses in the four-state area
NDT (Crisham, 1981)
Six client care dilemmas—considering
nurses principled thinking and
practical considerations
Pearson product
moment correlation

One-way analysis
of variance
Kim et al. (2007) Korea
Hospital environment
To examine changes in
nursing students’ moral
judgment after becoming
qualified nurses
80 nurses
Questionnaire JAND: Judgment about
Nursing Dilemma (Ketefian, 1981)
modified to a Korean population
(Kim, 1999)
Idealistic—realistic decision making
Paired t-test
Independent t-test

(ANOVA)
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n
a
ly
si
s
(2010) 635–650640
Hawker et al. (2002). This screening method enabled us to
evaluate the quality of both quantitative and qualitative
studies. We analysed the 38 studies on a number of
aspects, including method and analysis, ethical issues,
quality and strength of evidence, and their relevance to the
research question. With this system, it was possible to
calculate a summed score (9 = very poor; 36 = good),
reflecting the methodological strength of the studies.
The minimum score was 19/36 and the maximum score
was 33/36. In addition, the articles were assessed on the
criteria of validity, reliability (for the quantitative studies),
and the criteria of trustworthiness (for the qualitative
studies) (Polit and Beck, 2008).

The shortcomings of the quantitative studies mostly
were related to issues of confidentiality, sensitivity, and
consent. Most of the quantitative studies discussed the
reliability and validity of the instruments only to a limited
extent. The authors of these studies most often limited
themselves to a description of the development of the
instruments and to a report of internal consistency scores.
An obvious shortcoming of most of the qualitative studies
was a rather limited description of the samples, the
methods of data collection, and data analysis. Little
attention was spent on reflexivity and possible bias;
however, most authors did use a number of methods to
enhance the trustworthiness of their studies. All inter-
views were audiotaped and transcribed. Most used one
method for data collection, while Rodney et al. (2002) used
focus groups and open-ended questions. Tsaloglidou et al.
(2007) applied interviews and participant observation
techniques to collect data. Several researchers used
investigator triangulation for their analyses (Jansson and
Norberg, 1989, 1992; Carpenter, 1991; Erlen and Frost,
1991; Grundstein-Amado, 1992; Uden et al., 1992; Aström
et al., 1993; Norberg and Uden, 1995; Vogel Smith, 1996;
Varcoe et al., 2004; Monterosso et al., 2005). In addition,
member-checking and the audit trail under the form of
field notes, logs, and theoretical memos were used (Lützen
and Nordin, 1994; Oberle and Hughes, 2001; Rodney et al.,
2002; Tsaloglidou et al., 2007). Only two studies men-
tioned that saturation was reached (Carpenter, 1991; Uden
et al., 1992).
3. Findings
The ethical practise of nurses is a complex process that
combines the processes of ethical reasoning and ethical
behaviour (Vogel Smith, 1996; Dierckx de Casterlé et al.,

1997, 2008). The study of Vogel Smith (1996) labelled the
inter-related processes of ethical reasoning and ethical
conduct ‘deliberation’ and ‘integration’, respectively.
Deliberation or the process of reasoning by nurses involves
the consideration of the different factors that affect ethical
decision making. Integration concerns the implementation
of nurses’ decisions in clinical practise. Personal and
contextual factors play an essential role in both processes.
Examples of personal factors are nurses’ values, convic-
tions, experiences, knowledge, and skills. Contextual
factors include opinions and expectations of other nurses,
doctors, and family. They also include rules and routines,
and procedures and guidelines that are specific to wards in
Table 2
Qualitative studies included in the literature review.
Author(s) Country Aim(s) of the study Sample Data collection
Data analysis
Jansson and
Norberg (1989)
Sweden
Oncological, medical,
surgical clinics
To elucidate ethical reasoning of
experienced nurses concerning the

feeding of terminally ill cancer
patients
20 RN ‘good and experienced’ Structured interviews Qualitative
analysis
Coding scheme
Independent coding
Davidson et al. (1990) Canada, USA, Switzerland,
Finland,
Sweden, Australia, China,
Israel
Variety of acute care centres
To compare the ethical reasoning
of nurses associated with the
feeding of terminally ill elderly
cancer patients
169 nurses in 8 countries
‘good and experienced’
Structured interviews Qualitative analysis

Coding scheme
Carpenter (1991) USA
5 private agencies or hospitals
6 work settings affiliated
with the Roman Catholic church
9 agencies publicly owned
To examine the ethical
decision-making processes of
psychiatric nurses in clinical
practise
20 RNs who had worked
at least 1 year in a
psychiatric setting
Open-ended interviews Qualitative analysis
Thematic analysis
Erlen and Frost (1991) USA
Medical–surgical
Critical care setting

Psychiatric Hospital
To examine how nurses’
experiences influence ethical
decisions related to
patient care management
Convenience sample
25 nurses
In-depth interviews using
perceptions of nursing
ethics interview schedule
Content analysis
Independent coding
Grundstein-Amado
(1992)
Canada
Nurses
Acute-care setting
Long-term care setting

Doctors
Family practise
Internal medicine
Long-term care
To assess differences in the
ethical decision-making of nurses
and doctors
9 nurses
9 doctors
In-depth, semi-structured
interviews
Qualitative analysis
Jansson and
Norberg (1992)
Sweden
Nursing home
Psychogeriatric clinic
Somatic long-term clinic

To elucidate ethical reasoning of
experienced nurses working in
dementia care
20 nurses
8 head nurses
12 staff nurses ‘experienced
and good’
Structured interviews Qualitative analysis
Coding scheme
Independent coding
Uden et al. (1992) Sweden
Department of internal medicine
in an oncology university hospital
To examine the ethical reasoning in
nurses and physicians
Convenience sample
23 nurses
9 physicians

Interviews: narrations
of any ethically
problematic care
situation experienced
Independent coding
Narrative theory
Lützen and
Nordin (1993a)
Sweden
Various psychiatric settings
To conceptualise the experiential
aspect of moral decision-making
Purpose sample
14 nurses
(>5 years experience)
‘recommended by peers
and supervisors’

In-depth interviews Qualitative analysis
Grounded theory
(Glaser and Strauss, 1967;
Corbin and Strauss, 1990)
Contextual research
approach
Ethnograph for first and
second levels of analysis
Lützen and
Nordin (1993b)
Sweden
Hospital setting
Community clinic
To study the moral decision-making
experiences of nurses working in a
psychiatric nursing setting
14 nurses

‘competent and reflective’
In-depth interviews Qualitative analysis
Grounded theory
Contextual research
approach
S
.
G
o
e
th
a
ls
e
t
a
l./

In
te
rn
a
tio
n
a
l
Jo
u
rn
a
l
o
f
N
u
rsin
g
S
tu
d
ie
s
4

7
(2
0
1
0
)
6
3
5
–
6
5
0
6
4
1
Table 2 (Continued )
Author(s) Country Aim(s) of the study Sample Data collection
Data analysis
Sherblom et al.
(1993)

USA
3 hospitals in a large
metropolitan area
To describe nurses’ ethical concerns 31 female staff nurses
Interviews Qualitative analysis
Responsive reader method
Lützen and
Nordin (1994)
Sweden
Hospital setting
Community clinic
To study the moral decision-making
experiences of nurses in psychiatric
practise
14 nurses
‘competent and reflective’
Grounded theory

Contextual research
approach
Aström et al. (1993) Sweden
Hospital setting
Oncological, medical
and surgical
clinics in Northern Sweden
To examine the experiences of nurses
in ethically difficult situations
To define the expression ‘It depends
on the situation at hand’
18 nurses: 14 staff nurses
and 4 ward nurses

Phenomenology—
Hermeneutic
Aström et al. (1995) Sweden
Oncological, medical,
and surgical
clinics specialized in
cancer care
To explore how nurses manage
ethically difficult care situations
14 staff nurses, 4 head nurses
RR: 90% ‘experienced in
the care of cancer patients’
Structural analysis
Phenomenology—
Hermeneutic
Viens (1995) Mexico
A variety of primary care

settings in a large city in the
western United States
To describe and analyse the
process of moral reasoning
10 nurse practitioners Interviews Qualitative analysis
Phenomenology
Vogel Smith (1996) USA
Medical–surgical, paediatrics,
obstetrics,
and psychiatric units, and
various IC settings in one hospital
To examine the experience of staff
nurses in ethical decision-making
Random sample
19 nurses
Interviews Phenomenology
Ethnograph program
Giorgi’s method

(Giorgi et al., 1975)
Oberle and
Hughes (2001)
Canada
Adult medical–surgical units in one
large hospital
To examine similarities and differences
in the ethical reasoning of doctors
and nurses
Nominated sample
14 staff nurses ‘‘thoughtful
about ethical questions’,
7 doctors
Unstructured
interviews
Grounded theory
(Corbin and Strauss, 1990)

Thematic analysis
Rodney et al. (2002) Canada
Mid-sized metropolitan area
with one health region
Large metropolitan area with
several health regions
Settings: maternity, paediatrics,
medicine, surgery, critical care,
emergency, operating room,
oncology, psychiatry, rehabilitation,
long-term care, home care,
and community care
To examine the complexity of nurses’
ethical decision-making
Theoretical sampling 19 focus
groups: 3 groups
advanced-practise
nurses, 12 groups practising

nurses, 4 groups nursing
students, 87 participants
Focus groups
Open-ended trigger
questions
Constructivist methodology
(Lincoln and Guba, 1985)
Varcoe et al. (2004) Canada
19 practise settings
10 different organizations
To study the enactment of ethical
practise in nursing
87 nurses, 41 nurses mid-sized
metropolitan area, 46 nurses
larger metropolitan area
Focus groups Qualitative analysis
Interpretive constructivist
paradigm

Tsaloglidou
et al. (2007)
Greece
9-bed clinical nutrition unit—large
teaching hospital in UK
To determine nurses’ ethical
decision-making role in artificial
nutritional support
12 RN
2 consultants, 1 dietician
Participant observation
Semi-structured
interviews
Content analysis
S
.
G
o

e
th
a
ls
e
t
a
l./
In
te
rn
a
tio
n
a
l
Jo
u
rn
a
l
o
f
N

u
rsin
g
S
tu
d
ie
s
4
7
(2
0
1
0
)
6
3
5
–
6
5
0
6
4

2
Table 3
Mixed-method studies included in the literature review.
Author(s) Country Aim(s) of the study Design—sample Data
collection Data analysis
Care setting Response rate
Martin (1989) USA, Texas
Neonatal intensive
care units (NICU)
5 large urban hospitals
in the Southwest
To determine nurses’ involvement
in treatment decisions and factors
influencing their participation in
the decision-making process
83 RNs NEDMS: Nursing Ethical
Decision Making Scale
Semi-structured interviews

Frequency data
Ethnograph for analysis
Norberg
et al. (1994)
Sweden, USA, Australia,
Canada, China, Finland,
Israel
Nurses from institutions
providing high-quality care
To compare the ethical reasoning
of nurses in the feeding of a
severely demented patient who
seems to refuse food, this in a
variety of cultures
Structured interviews
Ranking of the ethical
principles

Coding scheme
Chi-square test
Chally (1995) USA
31-bed level III NICU Midwest
Two 10-bed adult ICU Midwest
To compare and contrast the
perspective used by nurses working
in neonatal and adult ICUs when
making moral decisions
Convenience sample
26 NICU nurses
25 adult ICU nurses
Semi-structured interviews
12 open-ended
interview questions
Identification of Care
and Justice Taxonomy
Demographic variables

and perspective
Interpretive method of analysis
Chi-square test
Norberg and
Uden (1995)
Sweden
Geriatric and surgical care unit
one large hospital
To determine whether gender and
different healthcare settings affect
the content and form of moral
reasoning
30 physicians
38 RNs
40 enrolled nurses (EN’s)
Interviews
Comparison between
physicians, RNs, and

enrolled nurses concerning
form and content of their
moral reasoning
Phenomenology—hermeneutic
Chi-square test
Mattiasson and
Andersson (1995)
Sweden
13 nursing homes in the county
of Stockholm
To explore ethical awareness:
autonomous vs. heteronomous
The following were assessed:
nurses’ personal opinion of the case,
unit’s anticipated decision regarding
the case, responses analysed from
the perspective of bioethical principles
Convenience sample

41 nurses
46 assistant nurses
83 nurse’ aides
17 other staff
Self-report questionnaire:
Hypothetical vignette
about restraint
Percentage per ethical
principle for personal
opinion and unit’s
anticipated opinion
Distribution of ethical
awareness
Content analysis
Frequency data
Holm et al. (1996) Denmark
5 internal medicine departments
To assess the ethical reasoning content

of nurses and physicians in terms of
style and time used by participants
21 physicians
20 nurses
7 Focus groups for
content analysis
Discussion style used
Discussion time used
Content analysis
Sign test
Fisher’s exact test
Mann–Whitney U test
Monterosso
et al. (2005)
Australia
2 NICUs of the sole perinatal
tertiary referral
centre of Western Australia

To explore to what extent nurses are
involved in complex clinical and
ethical decision-making
Nurses’ understanding of patient
advocacy in NICUs
Categories of infants causing most
concern in NICUs
Convenience sample
200 nurses
RR: 30% (n = 61)
Nurses were invited to
participate Questionnaire
contains: DCSN: Decisions
in Caring for Sick Newborn
Infants Questionnaire
Demographic characteristics
Patient advocacy
Nurses’ involvement in clinical

and ethical decision making
Open-ended questions
Descriptive statistics
Thematic analysis
S
.
G
o
e
th
a
ls
e
t
a
l./
In
te
rn
a
tio
n

a
l
Jo
u
rn
a
l
o
f
N
u
rsin
g
S
tu
d
ie
s
4
7
(2
0
1
0
)

6
3
5
–
6
5
0
6
4
3
(2010) 635–650644
which nurses work. Most of the studies analysed for this
review support aspects of the findings of Vogel Smith
(1996); therefore, we used their study as a guideline for
structuring and integrating the different research results in
this review.
3.1. Ethical reasoning
Many of the studies endorsed the complexity of the
reasoning process. From their ethical awareness, nurses
observe, analyse, and judge a given problem in a specific
care context. Nurses consider many factors that guide
them in their eventual ethical decision making (Vogel
Smith, 1996; Lützen and Nordin, 1993a; Carpenter, 1991;
Viens, 1995; Rodney et al., 2002; Grundstein-Amado,
1992). They weigh various alternatives, make choices, and

make decisions (Grundstein-Amado, 1992; Lützen and
Nordin, 1993a; Mattiasson and Andersson, 1995; Viens,
1995; Vogel Smith, 1996). To justify their decisions, they
rely on medical knowledge, personal values and experi-
ences, and the consequences of their possible choices
(Grundstein-Amado, 1992). As a result, the ethical reason-
ing process is embedded within the specific context and is
determined by nurses within the context of the nurse–
patient relationship. Here, given the important contextual
embeddedness of nurses’ ethical reasoning and decision
making, it cannot be reduced to its cognitive dimension.
Ethical reasoning is studied from various perspectives.
Grundstein-Amado (1992) and Holm et al. (1996) demon-
strated that nurses reason using different theories and
fundamental moral principles. They use deontological and
teleological theories or a combination of both. Research
into the ethical principles on which nurses ground their
analysis shows that they apply various ethical principles,
such as the principles of biomedical ethics, with a
preference for beneficence and respect for autonomy
(Garritson, 1988; Jansson and Norberg, 1989, 1992;
Davidson et al., 1990; Norberg et al., 1994; Mattiasson
and Andersson, 1995). They orient themselves from the
perspective of the ethics of care or from the ethics of justice
(Sherblom et al., 1993; Chally, 1995; Norberg and Uden,
1995; Kuhse et al., 1997). However, some authors
emphasized that the principles and perspectives that are
applied do not exclude each other, but that nurses
integrate both care and justice perspectives in their
decision-making processes (Sherblom et al., 1993; Chally,
1995). Both studies by Dierckx de Casterlé et al. (1997,
2008) indicated that nurses, when one applies the moral
development stages from Kohlberg (1981), attribute more
weight to conventional arguments (third and even fourth
stage) than to post-conventional arguments (fifth and
sixth stage).

Many of the studies that investigated ethical reasoning
described the personal relationship between nurses and
their patients. This caring relationship forms the context
for the ethical assessment (Martin, 1989; Uden et al., 1992;
Grundstein-Amado, 1992; Lützen and Nordin, 1993b,
1994; Chally, 1995; Viens, 1995; Vogel Smith, 1996;
Oberle and Hughes, 2001; Rodney et al., 2002, Varcoe et al.,
2004; Tsaloglidou et al., 2007). Driven by the ideal of care
and with the aim of ‘doing good’ for the patient, nurses take
the patient’s life history, feelings, wishes, intentions, and
integrity into account (Jansson and Norberg, 1989;
Grundstein-Amado, 1992; Lützen and Nordin, 1993b,
1994; Rodney et al., 2002). This finding is supported by
various studies that indicated that a nurse’s ethical
decision emerges as a result of the patient’s need for
specific care, which is also influenced by the nurse’s
relationship with the patient’s family and the team within
the context of treatment and care (Jansson and Norberg,
1989, 1992; Davidson et al., 1990; Aström et al., 1993;
Norberg et al., 1994; Viens, 1995; Vogel Smith, 1996;
Rodney et al., 2002; Varcoe et al., 2004).
As ethical reasoning is embedded in the personal
relationship between a patient and a nurse, the patient’s
and nurse’s personal qualities influence the ethical
decision-making process. Nurses are strongly driven by
values (Grundstein-Amado, 1992; Viens, 1995; Vogel
Smith, 1996; Dierckx de Casterlé et al., 1997; Penticuff
and Walden, 2000; Raines, 2000; Rodney et al., 2002;
Varcoe et al., 2004; Monterosso et al., 2005): convictions,
religion, education, and upbringing (Jansson and Norberg,
1992; Vogel Smith, 1996). In addition, nurses are inspired
by their intuitions and feelings as they undertake ethical
reflection (Lützen and Nordin, 1993a; Aström et al., 1995);
and by their personal and professional experiences

(Jansson and Norberg, 1989, 1992; Uden et al., 1992;
Grundstein-Amado, 1992; Viens, 1995; Vogel Smith, 1996;
Erlen and Sereika, 1997; Varcoe et al., 2004; Monterosso et
al., 2005).
Some studies indicated that ethical reasoning is
supported by medical and nursing knowledge and skills
(Grundstein-Amado, 1992; Lützen and Nordin, 1993a;
Vogel Smith, 1996; Varcoe et al., 2004; Tsaloglidou et al.,
2007). Nurses’ ethical reasoning was also influenced by
their collaboration with the patients’ family as well as with
colleagues, doctors of the ward, and the institution
(Jansson and Norberg, 1989, 1992).
Nurses find it very important to share their ethical
dilemmas with other nurses, to receive support, and to share
their decisions with their colleagues (Uden et al., 1992;
Aström et al., 1993; Raines, 2000). However, because nurses
seek to adhere to the majority view of the nursing staff, they
often put their own opinions aside (Jansson and Norberg,
1989, 1992; Davidson et al., 1990; Norberg et al., 1994).
Different studies stated that nurses changed their decisions
following a medical order (Jansson and Norberg, 1989, 1992;
Davidson et al., 1990; Norberg et al., 1994). These situations
can interfere with, influence, and change the development
of nurses’ conclusions (Uden et al., 1992; Grundstein-
Amado, 1992; Aström et al., 1993; Lützen and Nordin, 1994;
Oberle and Hughes, 2001; Rodney et al., 2002).
On the other hand, some elements facilitated ethical
decision making: education, guidelines, standards, sup-
portive colleagues (Rodney et al., 2002); and years of
experience at the same job (Erlen and Sereika, 1997). Other
factors hindered decision making: dominance within the
medical profession, a stressful work environment with
complex patient situations, insufficient resources, time,

and workload pressure (Oberle and Hughes, 2001; Rodney
et al., 2002). Corley and Selig (1994), Kyriacos (1995), and
Ham (2004) confirmed some of these impediments,
(2010) 635–650 645
reporting that experienced nurses in their ethical reason-
ing give more importance to practical considerations, like
time and means, and less weight to ethical principles.
The studies of Rodney et al. (2002) and Varcoe et al.
(2004) reported that nurses find a middle ground between
their values and those of their colleagues and institution.
These values often conflict with each other. Consequently,
the decision-making process of nurses is not always
straightforward and is characterized by a personal and
professional struggle to realise what is good for the patient.
Hereby nurses experience tension between their personal
values, professional ideals, and the expectations of others
(Lützen and Nordin, 1993a). Nurses experience an internal
conflict when their personal values and professional
responsibilities do not harmonize. This conflict can be
manifested as tension between the ‘morally correct’
decision and the ‘legally correct’ decision (Lützen and
Nordin, 1993b). How nurses cope with this tension may
differ greatly. Rodney et al. (2002) reported that nurses
looked for alternative solutions, like a wait-and-see
approach or leaving the decision to others. The studies
of Dierckx de Casterlé et al. (1997, 2008) reported that, in
difficult situations, conventional arguments (Kohlberg’s
third and even fourth stages), mostly influenced nurses’
decisions, indicating that their decisions were mostly
influenced by professional norms, laws, and rules. Thus,
nurses forsake their values and principles in order to adapt

to the opinions and expectations of others.
There are also, however, nurses who place their values
above professional expectations (Viens, 1995; Dierckx de
Casterlé et al., 1997, 2008; Raines, 2000; Corley and Selig,
1994; Ham, 2004). In the studies of Raines (2000) and
Corley and Selig (1994), 42.8% and 63% of nurses,
respectively, took this approach. Moreover, the studies
of Dierckx de Casterlé et al. (1997, 2008) observed that
expert nurses, whose capacity for ethical acting in nursing
dilemmas was estimated to be high, placed their values
above professional expectations. Indeed, the reasoning of
these nurses was not guided by the expectations of others
or by the customs of their environment but was guided by
their desire to provide the best patient care.
3.2. Ethical behaviour
The ethical behaviour of nurses is a strong relational
and contextual process in which personal and contextual
aspects play an important role (Vogel Smith, 1996; Varcoe
et al., 2004). In order for nurses to implement their decision
in practise, it is important they are allowed to act as patient
advocates. Additionally, consultation and a good relation-
ship between the involved actors are essential for the
process of integration. Having authority and power also
contributes substantially to the implementation of ethical
decisions in practise (Vogel Smith, 1996).
Various studies, however, indicated that a gap exists
between the ‘ideal’ ethical decision and the ‘real’ ethical
behaviour (Sherblom et al., 1993; Raines, 2000; Kim et al.,
2007). Some authors illustrated how nurses have difficul-
ties in implementing their decisions in practise (Uden
et al., 1992; Oberle and Hughes, 2001; Varcoe et al., 2004;
Dierckx de Casterlé et al., 1997, 2008). Many of the studies

showed that contextual factors often limited nurses’
abilities to implement their decision in practise or to act
according to their values and norms (Dierckx de Casterlé
et al., 1997, 2008; Varcoe et al., 2004; Oberle and Hughes,
2001; Rodney et al., 2002; Uden et al., 1992; Erlen and
Frost, 1991; Erlen and Sereika, 1997; Raines, 2000; Kim et
al., 2007; Penticuff and Walden, 2000; Sherblom et al.,
1993). Dierckx de Casterlé et al. (1997, 2008) reported that
the chance that nurses actually implement their decisions
becomes smaller when they are confronted with difficult
contextual circumstances. In such situations, nurses often
do not apply their decisions in practise but rather conform
to existing practises and group ethics.
Various studies showed that nurses are only indirectly,
occasionally, or not at all involved in the ethical decision-
making process (Martin, 1989; Monterosso et al., 2005;
Tsaloglidou et al., 2007). As a result, they often do not feel
personally responsible for their decisions, rather they feel
that their role as patient advocates becomes lost (Martin,
1989; Uden et al., 1992; Monterosso et al., 2005). Nurses also
experienced hierarchical relationships and traditional
structures of power in the work environment as obstruc-
tions, preventing them from acting ethically. Poor coopera-
tion with doctors, not being able to discuss their ethical
concerns, and a feeling of being ignored and not being
respected in their professional abilities all created barriers
that hindered nurses from acting on behalf of a patient’s best
interest (Martin, 1989; Erlen and Frost, 1991; Chally, 1995;
Tsaloglidou et al., 2007; Varcoe et al., 2004). These
circumstances gave nurses the impression that they had
little or no power to influence outcomes or the resolution of
ethical dilemmas (Erlen and Frost, 1991; Penticuff and
Walden, 2000). This often results in a reduced willingness to
take action when ethical dilemmas arise. Nurses who are
personally concerned about ethical dimensions and who

focus primarily on the morally relevant aspects of each
patient’s situation are more likely to be involved in dilemma
resolution activities (Penticuff and Walden, 2000).
Varcoe et al. (2004) reported that nurses often find
themselves lodged between the patient and the physician.
Contrasting values and expectations often lead to tensions
and conflicts in the provision of care, to which nurses
respond in different ways. They do not react immediately
in conflict situations but weigh the pros and cons. Various
elements are taken into account, including the personality
of the nurse, his or her position vis-à-vis the other actors,
the importance of the situation, implicit and explicit
customs of the institution, and the risk of negative
repercussions. Carpenter (1991) stated that nurses could
react in three different ways: They could directly address
the person with whom they are in conflict; they could act
indirectly; or they could do nothing. An example of
reacting indirectly is discussing the conflict with a
colleague, the head nurse, nursing staff, a social worker,
or a physician (Martin, 1989; Raines, 2000; Penticuff and
Walden, 2000).
Some nurses, however, do succeed in going against
deep-rooted routines, taking risks in order to act according
to their own values and norms (Lützen and Nordin, 1993b;
Viens, 1995). According to the results of Dierckx de
Casterlé et al. (1997, 2008), expert nurses have a higher
(2010) 635–650646
chance of effectively implementing their ethical decisions
in practise. They rely mostly on post-conventional argu-
ments (Kohlberg’s fifth and sixth stage) to implement their

decisions. Martin (1989), Aström et al. (1995) and Varcoe
et al. (2004) reported that knowledge, experience, risk
taking, boldness, and strong problem-solving capabilities
contribute to the fact that nurses eventually will act when
confronted with ethical problems. Besides personal factors,
contextual factors can also contribute to an active
intervention when ethical problems occur. Being involved
in ethical decision making, achieving a mandate in ethics
deliberations, and being able to positively collaborate with
physicians seem to prompt nurses to strive for the patient’s
best interest (Dodd et al., 2004).
Carpenter (1991), Erlen and Sereika (1997), and Raines
(2000) reported that difficult circumstances, rather than
ethical problems, hinder nurses from acting as they would
like and are the most important cause of moral distress.
Several authors concluded that these situations lead to
feelings of powerlessness, frustration, anger, dissatisfac-
tion, and exhaustion (Martin, 1989; Carpenter, 1991; Erlen
and Frost, 1991; Uden et al., 1992; Erlen and Sereika, 1997;
Penticuff and Walden, 2000; Raines, 2000; Oberle and
Hughes, 2001; Rodney et al., 2002; Varcoe et al., 2004).
Sometimes these situations cause burnout or even cause
nurses to leave the nursing profession altogether (Car-
penter, 1991; Oberle and Hughes, 2001).
Only one study (Dierckx de Casterlé et al., 1997)
examined the relationship between ethical reasoning and
the implementation of ethical decisions in practise. This
study reported a small but positive and significant
relationship between ethical reasoning and ethical beha-
viour (r = .18; p < 0.0001), indicating that the chance that
nurses implement an ethical decision in practise tends to
increase as their ability to make ethical deliberations
increases.

4. Discussion
4.1. Conceptual and methodological issues
Most of the studies reviewed by Ketefian (1989) were
based on Kohlberg’s theory on moral development and on
the quantitative paradigm. The international character of
this review as well as our inclusion of qualitative,
quantitative, and mixed-method studies allows us to
present a fairly balanced picture of how nurses actually
reason and behave ethically. This review, which analysed a
large number of qualitative studies and is mainly based on
the experiences of nurses themselves, provides insight into
the processes underlying nurses’ ethical reasoning. In the
quantitative studies, many different frameworks were
used and only a few studies relied on Kohlberg’s Moral
Development Theory. Because of the legitimate critiques of
his neglect of other elements such as context and emotion
the study of Dierckx de Casterlé et al. (1997) added a caring
perspective as well as some personal and situational
variables in the application of the rigid, abstract justice-
oriented theory of Kohlberg.
Ethical behaviour is examined in a far more limited and
almost indirect way, focusing on contextual factors related
to ethical behaviour that either enhance or inhibit this
behaviour. This finding illustrates the difficulty of actually
measuring ethical behaviour. Only one study (Dierckx de
Casterlé et al., 1997) alluded to the link between the
reasoning and behaviour processes. This limited outcome
makes it difficult to understand the relationship between
ethical reasoning and ethical behaviour.
When interpreting the results of this review, research-
ers need to consider some methodological shortcomings.
The use of various theoretical frameworks, concepts, and

definitions, and the unclear conceptualisation of the
concepts ‘ethical reasoning’ and ‘ethical behaviour’ lead
to highly fragmented research material that is difficult to
compare and integrate. A large variation in sample sizes
and response rates, possible non-responder bias, and
validation of the instruments restricted to small popula-
tions can limit the representativeness of results. Moreover,
by selecting mainly ethically competent nurses, many
qualitative studies may have presented an unrealistically
favourable or optimistic picture of nurses’ ethical practises.
Also, several studies were conducted in diverse research-
ing settings. Although this can be viewed positively as
reflecting different nursing cultures and positions in care
settings, a large diversity of research settings also makes it
even more difficult to clearly understand the ethical
practises of nurses.
4.2. Substantive findings
On the basis of our concern for the difficulties nurses
face as they endeavour to apply their ethical dimension of
care, we wanted to address in this review how nurses
reason and how they implement ethical decisions in
practise’.
Nurses’ ethical practise is a difficult and complex
process, in which an intricate web of personal and
contextual factors plays an important role in the reasoning
and behaviour processes. Most of the studies we analysed,
from their own perspective, provided us with insight into
the complexity of ethical practise and the difficulties that
nurses face when they are involved in ethical reasoning
and/or ethical behaviour.
The ethical reasoning process is complicated mainly by
the numerous factors that influence the ethical decision-

making process. As a starting point, nurses first consider
their own ethical stance. However, they must eventually
consider the values and expectations of patients, patients’
families, and others, in addition to the rules and routines of
their ward and institution. Due to these influencing factors,
nurses experience various difficulties that hamper their
personal decision-making process. Indeed, numerous
factors can hinder nurses from applying their ethically
desirable decisions to clinical practise: stressful work
environment, limited time and resources, lack of partici-
pation in the ethical decision-making process, confronta-
tion with opposing values and norms, and willingness to
conform to the expectations of others. As a result, nurses
are more likely to conform to the decisions of others.
Especially the difficult working conditions prevent
nurses from acting ethically. The impact of the context
on nurses ethical practise is not only supported by studies
(2010) 635–650 647
that rely on Kohlberg’s moral development theory. In a lot
of qualitative studies in this review, collecting nurses’
narratives, indicate that the context is not only a crucial
but also a problematic factor in their ethical practise. Using
Kohlberg’s cognitive approach, one could suggest that
nurses apply only a limited form of ethical reasoning, in
which they often stick to the conventional level when
faced with complex issues.
Due to their central position in patient care, nurses
seem to be the obvious persons to act as central figures in
the ethical decision-making process. Several studies in this
review show, however, that nurses are involved very little,

if at all, in this process, making it difficult for them to fulfil
their role as patient advocates (Martin, 1989; Uden et al.,
1992; Monterosso et al., 2005). Results from the study of
Milisen et al. (2006) corroborate these findings, stating
that 49% of nurses do not perceive themselves as having a
pivotal position in care. These findings are disappointing.
Because of their unique advocacy position in care, nurses
are privy to crucial patient information that can contribute
to a more person-oriented care. In this context, Peter et al.
(2004) pointed to the lack of clarity about the responsi-
bilities delegated to nurses. Because of their accessible
position in the care system and because they are driven by
their feelings of responsibility towards patients, nurses
often take over additional responsibilities from other care
workers. As a result, nurses are faced with more
responsibilities than they can reasonably handle with
the time and resources available. Such situations cause
nurses to feel like ‘task-oriented technicians’ rather than
the ‘caring professionals’ they would like to be. These
findings help us to understand why nurses, in the context
of ethical practise, experience an unbridgeable gap
between what they would like to do and what they only
can do in practise.
The qualitative studies we reviewed especially demon-
strate that nurses want to behave in a patient’s best
interest, while many of these studies highlight the
difficulties nurses face when they want to reason and
behave in the patient’s best interest. Nurses are inclined to
follow their intuitions and feelings, whereby ‘care’ and
‘doing good for the patient’ are the main motifs motivating
their behaviour.
The multi-facetted meaning of the concept ‘nursing
care’, as sketched by Gastmans et al. (1998), provides
insight into the motifs driving nurses’ actions. We consider

‘good care’ to be both a praxis and a moral endeavour, in
which attitudes and activities are the essential inalienable
components of nursing practise. This presupposes a caring
relationship between nurses and patients expressed in a
caring behaviour which is both technical accomplished
and virtuous. The development of a caring relationship
with the patient, which is in most cases reciprocal, is
essential for nurses’ ethical practice (Gastmans et al.,
1998). A reciprocal relationship positively affects the
mental well-being of nurses and results in feelings of
satisfaction and person growth, and leads to renewal
(Finfgeld-Connett, 2007). To which extent can nurses give
meaning to and experience satisfaction in their job given
the difficult circumstances in which they work? The results
of this review, which show how difficult working condi-
tions prevent nurses from acting ethically, are supported
by a large body of international literature demonstrating
that difficult working conditions do indeed have an impact
on nurses and patient care (Aiken et al., 2001; Peter et al.,
2004; Gutteriez, 2005; Nordam et al., 2005; Milisen et al.,
2006; Torjuul and Sorlie, 2006; Pendry, 2007). This
suggestion is particularly unfortunate when nurses feel
so unhappy with their job situation that they are
compelled to leave the profession, even though many
patients need their good bedside care (Peter et al., 2004;
Gutteriez, 2005; Milisen et al., 2006).
However, Vogel Smith (1996) also showed that good
cooperation with physicians is also important. Yet several
studies examined in this review showed that nurses
experience poor cooperation with physicians. This finding
is consistent with the findings of Siebens et al. (2006) in
which 43.3% of nurses reported a lack of teamwork
between physicians and nurses. Larson (1999) concluded
that lack of collaboration, coordination, and shared
decision making between physicians and nurses leads to

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