The oncology nursing staff faced a critical dilemma. A 70-year-old woman with advanced聽cancer was declining rapidly and unable to communicate. Her nurses strongly believed that聽her care should shift to comfort-focused measures. However, her oncologist disagreed,聽persuading the woman鈥檚 family that 鈥渟he鈥檚 a fighter鈥� and should receive immunotherapy.聽The nursing team believed that continued treatment was tantamount to torture, but felt聽helpless to stop it.
Aimee Milliken often presents this case study (a composite of several patient stories) when she addresses groups of nurses and aims to get them thinking and talking about the types of ethical challenges they face in their own practices. 鈥淲hen I present that case, I鈥檒l ask, 鈥業s this familiar?鈥� And the response is always a lot of head nodding,鈥� says Milliken, an associate professor of the practice at the Connell School of Nursing (CSON).
Milliken is one of several CSON faculty who are continuing a long tradition of helping students learn and implement the principles of nursing ethics. Together with Assistant Professor Melissa Uveges and Assistant Professor of the Practice Richard Ross, S.J., Milliken teaches a graduate course called Nursing Ethics and Professional Responsibility in Advanced Practice, which is focused on preparing advanced practice nurses for ethics leadership in health care. Moreover, 鈥渃omponents of ethics are interwoven throughout the nursing courses,鈥� says Milliken. 鈥淎s a school within md传媒国产剧 College, CSON places a huge emphasis on social justice and聽recognizing that, as nurses, we have obligations to our communities.鈥� In the classroom and through their research, these professors provide nurses withthe tools and strategies they need to ensure patients receive ethical care.
FOLLOWING A CODE
The American Nurses Association (ANA) established the first official nursing code of ethics in 1950, and has revised it every decade since. Milliken, who obtained a Ph.D. in nursing at BC in 2017, was a member of the writing panel that last updated the code, released in February 2025. In a 2018 paper, she spelled out the four major ethical principles that should guide every interaction a nurse has with a patient:
- autonomy, or the right to self-determination
- non-maleficence, or avoiding or minimizing harm
- beneficence, or the promotion of good
- justice, or the fair and equal distribution of benefits and burdens
鈥淚f an action is in conflict with a nursing goal or one of these principles, or if it ignores a patient鈥檚 preferences,鈥� she wrote, 鈥渢he nurse risks acting unethically.鈥澛�
Aimee Milliken
Milliken first became aware of the ethical challenges of patient care as a young nurse. When caring for an elderly patient in pain and poor health, she felt deeply conflicted by a family鈥檚 decision to keep the patient on life support鈥攁 decision that she felt did not preserve the patient鈥檚 dignity. She later learned the name for her experience: 鈥渕oral distress.鈥� Moral distress describes the frustration and powerlessness that occurs when a nurse feels unable to do what they feel is right due to ambiguous circumstances, like in Milliken鈥檚 experience, or some constraint, such as hospital policy, orders from a superior, or lack of resources.聽
鈥淢oral distress is ubiquitous in the profession of nursing and in health care generally,鈥� says Milliken, who has emerged as a leading authority on the problem and other issues in nursing ethics. In early 2021, during the height of the COVID-19 pandemic, she took over as executive director of the ethics service at Brigham and Women鈥檚 Hospital鈥攁 period when, according to the National Council of State Boards of Nursing, 100,000 nurses left the U.S. workforce, many citing stress and burnout.聽
鈥淭he experience of moral distress is contributing to burnout鈥攖o a sense of careers feeling unsustainable,鈥� says Milliken. She argues that systemic change is necessary to address some ethical quandaries nurses face, ranging from how to distribute scarce resources during a pandemic to how to create a more robust moral community. 鈥淏ut thinking about that can feel so overwhelming that it can be paralyzing,鈥� says Milliken. 鈥淪o I encourage nurses to ask: What system do I have control over? How can I identify problems and solve them within that system so that I don鈥檛 feel like I have to boil the ocean in order to solve this problem?鈥澛�
Milliken is frequently invited to speak about nursing ethics at conferences, including sessions in md传媒国产剧, Chicago, and Los Angeles this year. In her talks, she suggests skills that nurses can apply in situations like the case study about the oncology patient, including how to effectively communicate concerns about ethical issues that arise. 鈥淚t would be easy for the nursing staff to approach the oncology team with anger and say, 鈥楾his is wrong, we鈥檙e torturing this patient.鈥� That鈥檚 going to result in the oncology team getting defensive and digging their heels in,鈥� Milliken says. 鈥淚nstead, come from a place of inquiry and say, 鈥業鈥檇 like to hear more about your thoughts about this. Here are my worries.鈥欌��
鈥淭he experience of moral distress is contributing to burnout鈥攖o a sense of careers feeling unsustainable. So I encourage nurses to ask: What system do I have control over? How can I identify problems and solve them within that system?鈥�
鈥擜imee Milliken
Associate Professor of the Practice
鈥楨VEN IN THE VERY SMALL THINGS鈥�
Assistant Professor Melissa Uveges, who co-teaches and often collaborates with Milliken, received a doctorate in nursing from Johns Hopkins and studied decision-making for pediatric populations and their families as part of her postdoctoral research fellowship at the Harvard Medical School Center for Bioethics. She first began thinking about the role of ethics in nursing early in her career while working in a neonatal intensive care unit. The sequencing of the human genome had made it possible to test infants for genetic variants associated with diseases that may emerge years later. 鈥淭hat got me interested in the ethics of how we should be using these genetic technologies,鈥� says Uveges.
Melissa Uveges
The graduate ethics course at CSON enrolls about 35 to 40 students each semester. 鈥淥ne of the things we try to emphasize is that there are ethical implications even in the very small things we do as nurses,鈥� says Uveges. 鈥淔or example, think about an act as simple as starting an IV. You have to go through an informed consent process and make sure the patient understands why they鈥檙e getting an IV as well as the risks and the potential harms,鈥� she says.聽
Students come to the class with varying degrees of clinical experience but are in need of practice navigating the kinds of ethical challenges they鈥檝e already confronted. 鈥淚t鈥檚 an opportunity to pressure test everything you know,鈥� says Milliken. 鈥淲e try to provide frameworks for how to think about ethical issues.鈥� (See box.) In a typical class, students are presented an ethics case and the class discusses how it should be managed.聽
TOOLS FOR ETHICAL NURSING
Students in CSON鈥檚 graduate ethics course learn frameworks that nurses can apply to resolve ethical challenges in patient care, such as FESOR. This framework was introduced in a article coauthored by Martha Jurchak, Ph.D. 鈥�96, who was the former director of the Brigham and Women鈥檚 Hospital Ethics Service and Milliken鈥檚 mentor there.
Facts | Gather all relevant factual information about the patient and the ethical issue. |
Ethics Questions | Frame your question using ethical language. |
Stakeholders | Seek input from all parties affected by the decision, including family members and the interprofessional health care team. |
Options | Brainstorm about options to address the ethical issue. |
Recommendation | Based on the data obtained, make a recommendation to address the problem. |
Chris Charles
Chris Charles, D.N.P. 鈥�26, a nurse supervisor and clinical ethics consultant at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, valued the opportunity to work through cases in an academic setting. 鈥淧rof. Milliken would flip the script and push us by asking, 鈥榃hy do you think that way?鈥� She encouraged us to think through a case as ethicists.鈥�
Students also choose case studies from their own practices or the literature for analysis. 鈥淪ome of their cases are so compelling that they鈥檙e worthy of a broader readership, and we have been able to help students get them published,鈥� says Uveges, who co-authored a paper with Jessica Grasch, D.N.P. 鈥�26, that will appear in the journal AACN Advanced Critical Care this year. In it, they examined ethical considerations for nurses when a pregnant patient is suspected to have colorectal cancer. Meanwhile, Charles and Milliken co-authored a 2024 paper in in which they argued that COVID-19 vaccine mandates for nurses were justified by the ANA code of ethics. The paper was presented by Charles at the International Philosophy of Nursing Conference in Australia last fall.
BUILDING TRUST
Milliken and Uveges have made significant contributions to the field of nursing ethics outside their teaching at CSON. Milliken developed the Ethical Awareness Scale, a tool used in research and in clinical settings to measure how well nurses recognize and understand ethical issues in their daily work. Uveges is conducting research with colleagues at md传媒国产剧 Children鈥檚 Hospital with the goal of developing strategies that clinicians can use in conversations with families to promote children receiving testing for hereditary high cholesterol.
Both have co-authored widely used essential texts with CSON Professor Emerita Pamela Grace, a highly respected figure in the field of nursing ethics. Milliken partnered with Grace on (Springer, 2022), while Uveges joined her to co-author the fourth edition of (Jones & Bartlett Learning, 2023), for which she contributed a new chapter with Associate Professor and rare disease expert Andrew Dwyer on the ethics of genetic testing across the lifespan.
Polls have long shown nurses to be the most-trusted professionals in the United States, but if that trust is to be sustained against the growing mistrust of the health care system, nurses must maintain the highest ethical standards. 鈥淚t鈥檚 important right now for nurses to understand their ethical responsibilities at the bedside,鈥� says Uveges. 鈥淥nly then will we know how to move forward in a way that provides the best care possible.鈥澛�