Nursing ethics is distinct from medical ethics, and the difference is structural rather than a matter of emphasis. A physician typically decides and departs. A nurse remains at the bedside, carries out decisions she may not have made and may not agree with, and holds a duty to the patient that continues after everyone else has left the room. Most of the discipline's characteristic problems follow from that position.
The American code
The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements is the profession's authoritative ethical statement in the United States. It is non-negotiable — the Association's own framing — and although it is not law, it is routinely referenced in practice acts, employment standards, and disciplinary proceedings, which gives it more force than a voluntary document usually has.
The code was substantially revised in 2025, its first major revision since 2015. That revision expanded it from nine provisions to ten. The nine existing provisions were retained and edited, with both additions and deletions, and a tenth was added to address ethical issues that are global in nature. The revision was drafted by a panel of nurses from a range of settings and regions and went through public comment, drawing more than 6,300 responses from about 3,000 people.
The 2025 code is organized around six relationships, which is the clearest way to read it. Provisions one through three concern the nurse's relationship to the patient — respect for persons, primary commitment to the patient, and the duty to protect the patient's rights, health, and safety. Provisions four and six concern the nurse's relationship to other nurses, covering authority and accountability for practice and the duty to maintain an ethical practice environment. Provision five concerns the nurse's duty to herself, including her own health and integrity. Provision seven addresses the nurse's obligation to the profession, provision eight the relationship to others outside nursing, provision nine the relationship of nursing as a collective to society, and provision ten nursing's relationship to the global community.
Two substantive changes in the 2025 edition are worth naming: it explicitly identifies racism as a public health crisis, and it incorporates intersectionality as a way of understanding how overlapping factors shape health outcomes.
The international code
The International Council of Nurses maintains a separate code, most recently revised in 2021 with lessons from the COVID-19 pandemic incorporated. It is built on four principal elements: nurses and patients or other people requiring care or services; nurses and practice; nurses and the profession; and nurses and global health.
Nurses working internationally, or for organizations with an international scope, may be held to it in addition to their national code.
Provision five, which nurses skip
The duty a nurse owes to herself is the least-read part of the code and the one most often violated by good nurses. It covers preservation of wholeness of character and integrity, maintenance of competence, and continuation of personal and professional growth — and it explicitly includes the nurse's own health and safety.
This is why working while dangerously fatigued, remaining silent about impairment, and accepting assignments beyond one's competence are ethical failures under the code and not merely unwise. The provision exists because the profession's culture of self-sacrifice reliably produces harm to patients through exhausted nurses.
Advocacy against the employer
Patient advocacy is the code's most-quoted duty and the one that most often puts a nurse against her own institution. The 2021 revision of the parallel standards document added advocacy as a standard of professional performance in its own right, which signals how central the profession considers it. See scope of practice.
In practice this means the duty to report unsafe staffing, to question an order that appears wrong, to refuse an unsafe assignment, and to escalate when a patient's rights are being disregarded. The code offers no protection from the consequences of doing any of these things; whistleblower protections vary by state and are separate from the ethical duty. Nurses are frequently in the position of holding an unambiguous obligation and no institutional shelter for meeting it.
Conscientious objection
Nurses may decline to participate in care that violates deeply held moral or religious convictions. The right is not unlimited, and the code's constraints are important: objection must be made known in advance rather than at the moment of care, the nurse remains obliged to ensure the patient is not abandoned and that care transfers safely, and objection may not be exercised in an emergency where no alternative provider exists. Objection to a specific procedure is recognized; refusal to care for a particular kind of person is not.
Moral distress
Moral distress is the profession's characteristic ethical injury, named in the nursing literature by Andrew Jameton in the 1980s. It is the state of knowing the right action and being prevented from taking it by institutional constraint — a staffing level, a policy, a family's insistence, a physician's decision, a lack of authority.
It differs from an ethical dilemma, where the right course is genuinely unclear. In moral distress the nurse is not confused. She is constrained, and the accumulated residue of repeatedly acting against her judgment is strongly associated with burnout and with leaving the profession.
The organizational conditions that produce it — chronic short staffing, powerlessness in decisions about patients one is accountable for, and end-of-life care perceived as futile — are the same conditions the staffing research addresses from the outcomes side. See nurse staffing and patient outcomes.
Related
- Scope of practice
- Nurse practice acts and boards of nursing
- Nurse staffing and patient outcomes
- Nursing theory
Sources
- Code of Ethics for Nurses with Interpretive Statements, 2025 edition — American Nurses Association. Accessed September 8, 2026.
- About the 2025 Code of Ethics for Nurses — American Nurses Association, on the tenth provision and the six relationships. Accessed September 8, 2026.
- Revised ICN Code of Ethics for Nurses reflects lessons learned from the COVID-19 pandemic — International Council of Nurses, 2021. Accessed September 8, 2026.
- Updated nursing scope and standards — American Nurse Journal, July 2021, introducing Standard 8: Advocacy. Accessed September 8, 2026.