An ethical case study analysis
- Healthcare professionals face complex ethical challenges with regard to pediatric patients’ end-of-life decisions, particularly when patient autonomy conflicts with parental authority.
- Findings emphasize the importance of educating nurses on ethical dilemmas and providing structured support to foster moral resilience and mitigate moral distress, ensuring both ethical integrity and compassionate patient care.
- This study highlights the need for ongoing ethical education and interdisciplinary collaboration in nursing practice to equip nurses with the knowledge and tools necessary to navigate ethical complexities, ultimately enhancing the quality of patient care and professional well-being.
Salter presented the following ethical dilemma: Annie*, a 17-year-old girl with a terminal diagnosis, has an estimated 3 weeks to live. Both parents, who understand the situation, are religious and want to protect their child’s hope. They’ve requested that providers and nurses refrain from sharing the prognosis with their daughter. They want her to hear only that she’ll be healed. The healthcare team feels uncomfortable withholding this information because they believe it prevents Annie from preparing for her death. The crux of this ethical dilemma lies in deciding whether to disclose Annie’s prognosis to her.
End-of-life decisions present substantial ethical challenges for healthcare professionals, particularly when they involve pediatric patients whose rights may conflict with those of parents or guardians. Such dilemmas can result in substantial moral distress for nursing professionals. Viewed through an ethical lens, this complex case offers practical recommendations for nursing education and clinical practice. Analysis includes theories and provisions from the American Nurses Association (ANA) Code of Ethics for Nurses (Code) to evaluate the arguments for and against disclosing a pediatric patient’s terminal prognosis. (See Key terms.)
Key terms
Several terms are relevant to the ethics of disclosing a terminal prognosis to a minor.
- American Nurses Association Code of Ethics for Nurses—A set of guidelines designed to direct nurses in ethical decision-making and professional conduct.
- Ethics of care—A relationship-based ethical theory that focuses on motives, actions, and relationships in decision-making. It emphasizes empathy, compassion, and emotional involvement in care.
- Ethics of disclosure—The ethical considerations involved in deciding whether to share certain information with patients, particularly concerning their diagnosis and prognosis.
- Liberal individualism—A theory that prioritizes individual rights and personal autonomy. It supports the idea that individuals should be free to make their own decisions based on their values and beliefs.
- Mature minor—A minor with the cognitive and emotional capacity to understand and make informed decisions about their healthcare.
- Moral distress—Emotional and psychological stress experienced by healthcare providers when their belief in what is right conflicts with their ability to act accordingly.
- Parental authority—Parents’ legal and moral right to make decisions on behalf of their minor children.
- Veracity—The ethical duty to tell the truth to patients.
Sources: American Nurses Association; Beauchamp, Childress 2013; Gilligan 1982; Hijano, Yaun 2024; Icenogle et al 2019; Laslett 1988; Mill 1859; Olson et al; Yeo et al
Hamaideh and colleagues and Watson describe how educating current and future nurses in how to handle ethical dilemmas and providing them with structured support can foster moral resilience and mitigate moral distress. This education and support also can enhance the quality of patient care and contribute to the professional well-being of nursing staff.
Literature search
Using the following databases, we conducted a comprehensive search. Ultimately, we reviewed 21 articles in depth (following exclusion criteria).
- APA PsycInfo
- CINAHL
- Google Scholar
- MEDLINE
- Scopus
We included the following keywords:
- Adolescent decision-making
- Autonomy
- Beneficence
- Disclosure of prognosis
- End-of-life decisions
- Ethical dilemmas
- Ethics of care
- Family-centered care
- Mature minor
- Moral distress
- Nonmaleficence
- Nursing ethics
- Palliative care
- Parental authority
- Patient–provider trust
- Truth-telling in healthcare
- Veracity
Inclusion criteria focused on the following:
- Articles on adolescent autonomy and decision-making in healthcare
- Literature including guidelines from the ANA Code of Ethics
- Papers addressing nursing ethics in managing moral distress
- Research on patient–provider communication regarding prognosis disclosure
- Studies discussing ethical principles and theories relevant to pediatric end-of-life care
Exclusion criteria included the following:
- Academic, peer-reviewed studies not available in full-text
- Articles not written in English
- Literature older than 10 years unless considered seminal works
- Papers not focused on healthcare or nursing contexts
Following exclusion criteria, we reviewed 21 articles in depth.
In an effort to better understand the ethical dilemmas presented in this case and offer recommendations that might help equip nurses with some of the knowledge and tools necessary to navigate the complexities associated with pediatric end-of-life care, we conducted a literature review and analysis. (View Literature Search)
Literature review
The concept of therapeutic privilege has historically allowed physicians to withhold information if they deemed the disclosure potentially harmful to the patient. Today, according to Cole and Kodish, medical ethics emphasize patient autonomy and informed consent. Balancing parental authority and a child’s emerging autonomy remain crucial in pediatric care. Physicians must respect parents’ wishes while also considering the child’s right to be informed, particularly when the information pertains to a life-threatening condition.
Developmental stages and caregiving environments influence grief reactions in children and adolescents. Crico and colleagues note that the inclusion of prolonged grief disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, highlights the need for developmentally appropriate grief assessments. Caregivers play a pivotal role in facilitating adaptive grieving processes. Open communication about a diagnosis can help mitigate maladaptive grief reactions—such as depression, anxiety, withdrawal, or risk-taking behaviors—suggesting that honest disclosure to a mature minor supports their emotional well-being.
Nurses frequently face moral distress when ethical dilemmas arise, particularly in end-of-life care. The Code emphasizes the nurse’s commitment to the patient, including advocating for honesty and informed consent. Research by Cole and Kodish indicates that disclosing a prognosis to children doesn’t necessarily increase anxiety and can provide a sense of control and preparedness.
Crico and colleagues describe clinical ethics committees (CECs) as providing a structured approach to addressing ethical dilemmas in healthcare. CECs can assist in evaluating the ethical complexities of disclosing a prognosis to a minor against parental wishes, ensuring that nurses and providers make decisions with a comprehensive understanding of ethical principles and in the patient’s best interests.
Analysis
Our analysis used the underlying ethical theories of liberal individualism, ethics of care, and the Code as models for practical application. We began by familiarizing ourselves with Annie’s case, as well as current legal and medical literature. We applied the theories through written reflections and discussion. Our analysis also underwent several external reviews to enhance its objectivity and credibility. (See Theory application.)
Ethical support for telling the patient
As described by Locke, Mill, and Marceta, liberal individualism guides choices based on which side has the most ethical support. In this framework, Annie, as a mature minor, has the right to know about her prognosis, receive adequate palliative care, and make arrangements in her last weeks of life. The argument centers on knowledge rather than complete autonomy, suggesting that patients deserve to fully comprehend their situation and live their remaining time clearly and without regrets.
Ethical support against telling the patient
The relationship-based ethics of care theory focuses on motives, actions, and relationships in decision-making. This framework considers the impact of disclosing Annie’s prognosis on her life, her parents’ lives, and on interpersonal relationships.
The parents’ motives appear to center on preserving their daughter’s remaining hope and shielding her from the emotional burden of a terminal prognosis. Their actions reflect a commitment to Annie’s well-being, and no current evidence of strain on their familial relationship exists. By withholding the information, the parents can maintain their parental role and family unity, consistent with the ethics of care.
Theory application
Liberal individualism, ethics of care, and the American Nurses Association (ANA) Code of Ethics for Nurses (Code) can be applied in Annie’s case study.
Liberal individualism
Ethics of care
ANA Code
Translate this case analysis into concrete outputs that move the profession forward:
- in-service module on disclosure to mature minors
- unit guidelines that trigger ethics consults when parents request nondisclosure
- policy brief supporting statewide mature-minor statutes
Sources: American Nurses Association, Gilligan, Laslett, Mill
Evidence supporting both sides
The Code provides a comprehensive framework that supports ethical nursing practice, offering guidance applicable to both sides of this ethical dilemma. By emphasizing the importance of compassionate care, patient advocacy, and professional integrity, the Code allows nurses to navigate complex situations while upholding the highest standards of ethical conduct. In the case of Annie, the Code can be interpreted to support either disclosing or withholding the patient’s prognosis, highlighting the need for advanced ethical reasoning in pediatric end-of-life care.
For example, Provision 2 of the Code supports honesty with Annie, emphasizing the nurse’s primary commitment to the patient. Despite the family unit holding more legal weight in the case of minors, Annie must remain the nurse’s ethical priority. Research by Cole and Kodish indicates that disclosing a prognosis to children doesn’t necessarily increase anxiety and may even reduce it. Honest communication could alleviate Annie’s anxiety, providing her with a sense of control in her final weeks, thereby fulfilling ethical obligations and enhancing her quality of life.
In contrast, Provision 3 of the Code underscores the nurse’s role in promoting and protecting the patient’s health, safety, and rights, which includes acting on questionable medical practices. The potential emotional and spiritual harm that could result from disclosing Annie’s prognosis and the possible violation of her parents’ rights require a cautious approach. This involves supporting the parents’ decision to withhold the prognosis and protecting Annie’s best interests and her parents’ rights.
Ethics in action
Annie’s story has significant implications for nursing professionals, who frequently provide end-of-life care and must manage similar ethical dilemmas. Ensuring nurses have the knowledge, skills, and attitudes necessary to navigate these complex ethical situations requires education on ethical principles and providing ethical action. Research (Watson, Lok and colleagues, Aryuwat and colleagues, and others) notes that proactive ethical education and nursing support in challenging patient care scenarios can foster nursing resilience by mitigating the effects of moral distress, which ultimately contributes to a healthy work environment.
Although nurses must know their state’s regulations around mature minors and their rights, making ethical decisions in such cases can’t rely solely on legal statutes to determine the best course of action for an individual patient. Annie’s story highlights fundamental principles of nursing practice: respect for patient autonomy and informed consent. (See Action items.)
Action items
The following action items support nurses who face ethical dilemmas while caring for patients.
Sources: American Association of Critical Care, American Nurses Association
Our analysis also supports consideration of the sociocultural context of the patient, the patient’s family, the nurse, and the healthcare team. An open mind to potential differences may help everyone involved successfully navigate ethical reasoning and mitigate moral distress. (See Cultural considerations.)
Cultural considerations
Keeping an open mind about cultural differences can help nurses manage ethical dilemmas and reduce the potential for moral distress.
Sources: Beauchamp and Childress, Katz et al, Varkey, Yeo et al
A call for ongoing education
In healthcare, ethical dilemmas remain unavoidable. In Annie’s case, disclosing her prognosis is appropriate and aligns with ethical principles, theories, cultural considerations, and provisions outlined in the Code. By providing truthful information, healthcare providers facilitate informed patient decisions and, ideally, adequate time to prepare for the end-of-life.
Nurses should handle similar situations sensitively, taking into consideration the patient’s developmental stage and family dynamics. Ultimately, prioritizing the patient’s well-being involves understanding ethical principles and individual circumstances to ensure compassionate and ethical care. This case serves as a tool for current and future nurses to identify key ethical principles, theories, and provisions that may prove integral to navigating future dilemmas in their practice.
Rather than reacting to ethical dilemmas based on personal opinions and experiences, nurses must rely on available resources to explore complex scenarios. To meet that requirement, nurses must receive comprehensive initial and ongoing education on the resources available to them. They should be able to recognize situations that require the use of these resources and stay familiar with the current body of knowledge relevant to healthcare professionals.
*Name is fictitious.
Adrianna Watson is an assistant professor at Brigham Young University in Provo, Utah. Rachel Clement is a nursing graduate from Brigham Young University.
American Nurse Journal. 2025; 20(10). Doi: 10.51256/ANJ102528
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Key words: nursing ethics, patient rapport, pediatrics, palliative care
