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 Boston 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 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 皇冠官网 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 s