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 family that 渟he a fighter� 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. 淲hen I present that case, I檒l ask, 業s this familiar?� And the response is always a lot of head nodding,� 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, 渃omponents of ethics are interwoven throughout the nursing courses,� says Milliken. 淎s a school within Boston College, CSON places a huge emphasis on social justice and聽recognizing that, as nurses, we have obligations to our communities.� In the classroom and through their research, these professors provide nurses with the 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 51动漫 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
淚f an action is in conflict with a nursing goal or one of these principles, or if it ignores a patient preferences,� she wrote, 渢he nurse risks acting unethically.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 decision to keep the patient on life support攁 decision that she felt did not preserve the patient dignity. She later learned the name for her experience: 渕oral distress.� 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 experience, or some constraint, such as hospital policy, orders from a superior, or lack of resources.聽
淢oral distress is ubiquitous in the profession of nursing and in health care generally,� 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 Hospital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
淭he experience of moral distress is contributing to burnout攖o a sense of careers feeling unsustainable,� 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. 淏ut thinking about that can feel so overwhelming that it can be paralyzing,� says Milliken. 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檛 feel like I have to boil the ocean in order to solve this problem?澛�
Milliken is frequently invited to speak about nursing ethics at conferences, including sessions in Boston, 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. 淚t would be easy for the nursing staff to approach the oncology team with anger and say, 楾his is wrong, we檙e torturing this patient.� That going to result in the oncology team getting defensive and digging their heels in,� Milliken says. 淚nstead, come from a place of inquiry and say, 業檇 like to hear more about your thoughts about this. Here are my worries.櫇
淭he experience of moral distress is contributing to burnout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?�
擜imee Milliken
Associate Professor of the Practice
楨VEN IN THE VERY SMALL THINGS�
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. 淭hat got me interested in the ethics of how we should be using these genetic technologies,� says Uveges.
Melissa Uveges
The graduate ethics course at CSON enrolls about 35 to 40 students each semester. 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,� says Uveges. 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檙e getting an IV as well as the risks and the potential harms,� 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檝e already confronted. 淚t an opportunity to pressure test everything you know,� says Milliken. 淲e try to provide frameworks for how to think about ethical issues.� (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 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. �96, who was the former director of the Brigham and Women Hospital Ethics Service and Milliken 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. �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. 淧rof. Milliken would flip the script and push us by asking, 榃hy do you think that way?� She encouraged us to think through a case as ethicists.�
Students also choose case studies from their own practices or the literature for analysis. 淪ome of their cases are so compelling that they檙e worthy of a broader readership, and we have been able to help students get them published,� says Uveges, who co-authored a paper with Jessica Grasch, D.N.P. �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 Boston Children 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. 淚t important right now for nurses to understand their ethical responsibilities at the bedside,� says Uveges. 淥nly then will we know how to move forward in a way that provides the best care possible.澛�