One day, I witnessed a colleague engaging in unsafe and unprofessional behavior. The colleague repeatedly documented that a wound dressing had been changed even though it hadn’t actually. At that time, I believed I was facing an ethical dilemma because I wasn’t sure what to do. Reporting the behavior could harm workplace relationships, while not reporting it could jeopardize patient safety.
What is an ethical dilemma?
According to Etymonline, the word dilemma comes from the ancient Greek, combining di- meaning “two” and lemma meaning “premise” or “proposition.” Therefore, an ethical dilemma can be understood as a situation in which two or more conflicting ethical principles are present. However, many use term too broadly, even when conflicting principles aren’t actually involved.
How is a dilemma different from an ethical issue?
Many people, including myself, sometimes confuse ethical issues with ethical dilemmas. Ethical issues frequently arise in daily practice and are generally straightforward. The right answer is usually clear, and we can make correct decisions quickly by following established guidelines such as the American Nurses Association Code of Ethics for Nurses (the Code). On the other hand, as described by Beauchamp and Childress and by Haahr and colleagues, an ethical dilemma occurs when two or more ethical principles or standards are in conflict, creating a situation without a single clear answer.
One example of an ethical issue is when a competent adult patient who refuses a blood transfusion. At first glance, this situation may seem like a dilemma because healthcare providers inherently seek to preserve the patient’s life. However, if the patient has decision-making capacity and clearly refuses the transfusion after being fully informed, then we must respect the principle of autonomy. In this case, the patient’s right to self-determination takes precedence, making the appropriate course of action clear. Therefore, this situation constitutes an ethical issue rather than a true dilemma.
In contrast, a true ethical dilemma may arise when the patient lacks decision-making capacity or when the patient is a child. Imagine a child who requires a blood transfusion, but the parents refuse it for religious reasons. In this scenario, the principles of parental autonomy, beneficence, and the child’s best interests come into conflict. Such conflicts, where no single principle can decisively prevail, constitute the essence of an ethical dilemma.
Why do we need to distinguish between the two?
In today’s complex healthcare environments, nurses frequently encounter ethically challenging situations. For this reason, ethical competence has become a fundamental component of professional nursing, and many nursing organizations have highlighted its importance. The Code establishes the standard for ethical nursing practice, emphasizing professional integrity and accountability in care delivery. Similarly, the International Council of Nurses Code of Ethics provides a framework that defines nurses’ ethical values and responsibilities to guide practice.
Mislabeling a straightforward ethical issue as a dilemma not only complicates something that could otherwise be resolved easily but also may lead to negative consequences typically associated with genuine dilemmas, including work-related stress, burnout symptoms, turnover intent, and reduced team effectiveness, as demonstrated by Larsman and colleagues in their longitudinal study. Therefore, having a clear understanding of what constitutes an ethical dilemma is an important step in effectively addressing ethical challenges.
Simply recognizing when a situation isn’t a true dilemma can help clarify the appropriate course of action and facilitate resolution. In this context, nurses require opportunities to reflect on and discuss experiences they perceive as ethical dilemmas. This process helps prepare them to become ethically competent professionals who can confidently navigate complex ethical situations.
Practical takeaways
Looking back, the situation I shared at the beginning wasn’t a true ethical dilemma but an ethical issue. According to professional codes and the obligation to protect patient safety, the correct course of action was clear: I needed to report the behavior.
Distinguishing clearly between ethical issues and true ethical dilemmas is a key aspect of professional nursing practice. Ethical issues, while sometimes uncomfortable, usually have clear answers guided by professional codes and can be addressed promptly. Ethical dilemmas, however, are less common and require deeper reflection and collaboration. In such cases, seeking guidance from colleagues or ethics committees and engaging patients and families in open discussion can help identify the best possible path forward. By applying this distinction in practice, we can focus our efforts more productively and feel empowered to address the complex ethical challenges we encounter.
Hyeyoung Hwang MSN, MBE, RN, OCN is a doctoral student at the Johns Hopkins School of Nursing in Baltimore, MD.
References
American Nurses Association. Code of Ethics for Nurses. 2025. codeofethics.ana.org/provisions
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford, UK: Oxford University Press; 2019.
Etymonline. Origin and history of dilemma. etymonline.com/word/dilemma
Haahr A, Norlyk A, Martinsen B, Dreyer P. Nurses experiences of ethical dilemmas: A review. Nurs Ethics. 2019;27(1):258-72. doi:10.1177/0969733019832941
International Council of Nurses. The ICN Code of Ethics for Nurses. 2021. icn.ch/sites/default/files/2023-06/ICN_Code-of-Ethics_EN_Web.pdf
Larsman P, Pousette A, Nilsson MS, Gadolin C, Törner M. Ethical value conflicts in healthcare and their effects on nurses’ health, turnover intent, team effectiveness, and patient safety: A longitudinal questionnaire study. Scand J Work Environ Health. 2024;50(2):113-21. doi:10.5271/sjweh.4138
