Ethics Is Essential Free

Ethical behavior—including honesty and trust-worthiness—is essential to health professions. Public trust and respect for the ethical integrity of nurses, physicians, and all heath care team members is built on a social contract that requires embedding of ethics into every professional activity. Provision of safe and effective care requires ethics. Building new knowledge for practice requires scientific integrity. Educating new practitioners requires an ethical framework. Establishing and maintaining healthy work environments requires ethical behavior. In this editorial, we reflect on 4 events that move the discussion of ethics in critical care practice and research forward: the newest Gallup poll ranking ethics of professions in the United States,¹  publication of an updated code of ethics for nurses by the American Nurses Association (ANA),²  resumption of the American Journal of Critical Care (AJCC) ethics column³  beginning in this issue, and an invited AJCC commentary on critical care nursing.⁴ 

The ethics of health professionals matters to the public. For the 23rd year in a row, nurses ranked No. 1 in the “most honest and ethical professions” Gallup poll. The annual poll of Americans’ perceptions of 23 professions was conducted in December 2024.¹  Nurses have ranked first in the poll every year since their inclusion in 1999, with the exception of 2001 (in the wake of 9/11, firefighters were ranked first and nurses second). Health care professions have traditionally ranked well in the poll. This year, pharmacists were ranked third and medical doctors fifth, placing them among only 5 professions with majority positive ratings of “very high” or “high.” Although public perception of a profession’s ethics may not be a true reflection of a profession’s actual ethical behaviors, it is an important indicator of the trust and respect that underlie therapeutic relationships in health care.

Ethics are inculcated in the health professions through formal education, professional organizations, and daily behaviors that reveal and reinforce the professional culture. Consensus about ethical standards is embodied in professional codes of ethics. Shared understanding of what is good and right is also gained through dialogue among members of a profession, with their interdisciplinary colleagues, and with the people they serve.

What is mandatory and what is expected are explicated in formal codes of ethics for health care professions. The first formal code of ethics for nursing in the United States was adopted by the American Nurses Association (ANA) in 1950, and the most recent updated version was published in January 2025. The ANA’s code of ethics for nurses constitutes a “nonnegotiable moral standard of nursing practice for all settings.”^2(pxi) The preamble to the ANA code notes,

The ANA code is structured around 10 provisions that describe ethical obligations in 7 pivotal relationships for nurses: obligations to the patient, to other nurses, to the self, to the profession, to others, to society, and to the global community. The provisions provide a broad framework for ethical reasoning and behavior. Application to specific situations require thought and reflection; guidance and consultation with nurse ethicists and others can be indispensable in dealing with ethical dilemmas as they arise in clinical care.

In the January 2025 editorial, we alerted readers that a newly revived ethics column was planned,⁵  and the first column in this new series debuts in this issue of AJCC.³  We are thrilled to welcome Dr Catherine Green, a nurse ethicist, as the columnist. Catherine’s interest in ethics was fostered by her bedside experience as a critical care nurse and more fully developed in her PhD program in philosophy. In her work as a nurse ethicist, she is particularly interested in ethical dilemmas encountered by staff nurses in critical care.

Her first column lays out an approach for thinking about ethics that is welcoming, pragmatic, and engaging. In this first column, she says, “Any time someone raises an ethical concern, they are expressing a concern about what is good or right for some particular person or group.”^3(p240) She goes on to say,

She provides a framework of 7 aspects of human nature that inform ethical thinking in critical care. A QR code accompanying the column provides opportunity to provide direct feedback and pose questions or situations for future consideration in the column—advancing Green’s hope that we will (virtually) put our heads together to examine ethical issues. We envision the column as an important means to engage our readers, to assist critical care nurses to build ethical reasoning skills, and to foster dialogue on difficult issues encountered by bedside nurses and critical care teams.

We are also pleased to present in this print issue of AJCC a commentary by members of the American Academy of Nursing Acute and Critical Care Expert Panel (an electronic version was published ahead of print on February 4).⁴  The expert panel recently published a call to action⁶  that identified 9 domains of acute and critical care nursing practice. The domains align with the ANA’s Nursing Scope and Standards of Practice, including ANA standard 7, “The registered nurse practices ethically.”⁷  The call to action proposed how nurses’ work could be better recognized, measured, and supported. The AJCC invited commentary provides insight into the reasoning of the expert panel in developing the call and an overview of the domains, as well as summarizing essential elements of hospital environments that are needed to fully support nurses (what they refer to as “nursing nirvana”). They argue that measuring nursing care by what is not done (absence or failure of care) is inadequate to capture the value of nursing care that is done (patient- and family-sensitive measures of outcomes—the actual work of nursing). They also note that current systems engender moral distress: “The emotional distress experienced by nurses during the resolution of ethical problems is endemic to inpatient care.”^4(p238) The work of the expert panel dovetails nicely with provision 4 of the 2025 ANA code of ethics, which elaborates on the ethical duty of nurses to recognize and address social, environmental, political, legislative, and economic constraints that limit nursing practice authority.² 

We end with a cautionary note. Although the Gallup Poll rankings indicate that the ethics of nurses, physicians, and other health care professionals continue to be appreciated by the public, a longitudinal view of the Gallup poll data¹  also reveals that the percentage of people indicating positive regard (“very high” or “high” rating) has diminished in the past 4 years. Between 2010 and 2019, positive ratings for nurses ranged between 80% and 85% and positive ratings for medical doctors ranged between 65% and 70%. Positive ratings peaked mid-pandemic in 2020 for both nurses (89%) and medical doctors (77%). The positive ratings have fallen each year since then, with nurses ranked at 77% and medical doctors at 53% positive ratings in 2024. Gallup attributes declining percent positive ratings to less trust in professions and in institutions generally. It is imperative that nurses, physicians, and all health professionals continue to focus on the importance of ethics in all we do and that we interact with our patients and their families in ways that reinforce our trustworthiness and demonstrate our commitment to what is good and right in health care.