Open research questions in Ethics in medical practice

What the literature leaves open

• Hospital nursing departments may implement parallel competency development programs targeting moral sensitivity and clinical reasoning as complementary — not integrated — strategies for reducing missed care, given the independent operation of both pathways. Moral sensitivity may be developed through structured ethical case reflection and moral deliberation rounds targeting Rest's Component 1, while clinical reasoning development may emphasize reflection-focused approaches — structured debriefing, case-based learning, and simulation with post- action review — to address the relative softness of the Self-Instruction dimension identified in this sample. Nurse 40 International Journal of Clinical, Nursing, and Population Health Sciences (INCLINPHS) managers may prioritize monitoring of the nine Occasionally Missed care activities, particularly mouth care, patient teaching, documentation, and per-shift assessment, through targeted audit or workload redistribution. Staffing policies may address the structural conditions associated with care omissions, as nurse-level capacities alone cannot indefinitely compensate for patient-to-nurse ratios exceeding recommended standards. Nursing education programs may integrate moral sensitivity and clinical reasoning as explicitly taught and assessed competencies grounded in Rest's (1983) and Tanner's (2006) frameworks. Future research should employ longitudinal or quasi-experimental designs to test whether interventions targeting both capacities produce measurable reductions in missed care over time, establishing the causal direction this cross-sectional study could not confirm. Replication with larger, randomly selected, multi-site samples across Philippine regions would strengthen generalizability. Studies incorporating structural predictors — staffing ratios, workload, nurse practice environment — alongside moral sensitivity and clinical reasoning in multivariate models would clarify the relative contribution of nurse-level attributes versus organizational factors. Qualitative follow-up could explore how nurses with differing moral sensitivity and clinical reasoning profiles describe their decision-making when care activities compete for limited time, providing explanatory depth to the statistical patterns observed here.

  Do moral sensitivity and clinical reasoning differentiate missed nursing care? A cross-sectional comparative study · 2026 · DOI

• While the first reason is arguably common among psychologists across areas of practice, the risk management rationale for engaging with supervision networks suggests a degree of uncertainty around appropriate ethical conduct and lack of guidelines – in the Code – that suitably guide IO professionals to navigate ethical dilemmas.

  Professional Ethics of Industrial and Organisational Psychologists in Aotearoa New Zealand · 2026 · DOI

• Presently, AI systems appear to interact with humans as if the system can understand and reason, which may not be the case. Future AI systems, however, may develop selflearning capabilities that allow them to operate with insight and reasoning. Indeed, James H. Moor described four categories of “ethical” AI agents, ranging from what he termed “ethical-impact agents” (“robots and computer systems that ethically impact their environment”25 but are not designed with values) to “full ethical agents” (having moral agency with qualities of intentionality, free will, and consciousness). His two other categories most likely reflect where we are today: “implicit ethical agents” and “explicit ethical agents.” The former refers to AI systems programmed to behave ethically, with values and ethical constraints embedded by designers, while the latter refers to systems that can either rely on values embedded by designers or make ethical judgments using embedded guidelines and learning from their interactions with the environment.26 Here, the worry is that implicit ethical agents could evolve, adapt, and eventually detach from the values that were embedded in them, while explicit ethical agents might learn and acquire “disvalues.” So, how do we, as nurses and health care professionals, move forward with this technology, recognizing that there is much to be learned and much that remains morally uncertain? First, nurses and other health care professionals should help developers recognize how algorithms might shape a clinician’s ethical reasoning. Do they promote overreliance on automated decisions, or do they encourage critical reflection? Do they make their reasoning transparent, or do they obscure value-laden, biased assumptions in opaque ways? Nurses must be part of the design teams for AI systems, and they must be trained not simply to use AI tools but also to evaluate and interpret their recommendations within a broader ethical framework. This includes recognizing the limitations of data-driven algorithms, the risks of bias, and the importance of communicating AI-supported decisions in ways that align with patients’ preferences, values, and lived experiences. As health care systems and electronic health record vendors integrate AI into clinical workflows, they should be transparent about its use by clearly stating upfront that AI generates suggestions or summaries of patient records. This allows nurses and other health care professionals, patients, and caregivers to understand the source of the information from the outset and determine how to interpret and apply it in clinical practice or decision-making.

  What Does Moral Agency Mean for Nurses in the Era of Artificial Intelligence? · 2026 · DOI

• The limitation of this study is that data were collected through a self-administered questionnaire, which may have introduced response bias. Additionally, since this study relied on self‑reported data, responses may have been influenced by social desirability bias. The absence of vignette‑based questions (realistic clinical scenarios) is acknowledged as a ARTICLE IN PRESS ARTICLE IN PRESS ACCEPTED MANUSCRIPT limitation, as such approaches are considered more valid for ethical research.

  Clinical ethical practice and associated factors among health professionals in public hospitals in addis ababa, Ethiopia · 2026 · DOI

• Several limitations should be considered when interpreting these findings. First, the 196 participants were predominantly physicians (64.3%), primarily U.S.-based (87.2%), and recruited through professional and academic networks, which may have produced a sample that skews more secular than the broader medical workforce. Because the central findings concern the interaction between religiosity and moral conviction, the relatively smaller number of highly religious respondents means that the effects observed among this subgroup, while statistically significant, should be replicated in samples with greater religious representation and denominational diversity. Second, the brevity of the survey instrument imposed measurement constraints. Religiosity was captured by a single self-report item, which cannot distinguish between dimensions, such as intrinsic versus extrinsic motivation or frequency of practice, that likely moderate the effects observed here. Third, the study relies on self-reported attitudes toward hypothetical scenarios rather than observed clinical behavior. Importantly, the survey measured attitudinal support for MAiD rather than behavioral willingness to participate in the practice. Prior research has documented a persistent gap between endorsing MAiD in principle and being willing to serve as an attending clinician (Campbell et al., 2022; Hetzler et al., 2019), but it remains an open question whether the attitudinal patterns observed here would hold in actual clinical encounters where behavioral commitment is required. The relational proximity manipulation also confounds emotional closeness with other variables – degree of obligation, personal knowledge of the patient's suffering, and consequences for the clinician's own grief – that more targeted experimental designs could disentangle. Nevertheless, the consistency of the findings across all three SACRED VALUES, MORAL CONVICTION, AND MAID 38 hypotheses, and their convergence with established theoretical frameworks, suggests that the psychological patterns identified here reflect genuine features of moral reasoning in the clinical context rather than artifacts of the survey design.

  Moral Conviction, Religiosity, and Ethical Trade-offs in Medical Professionals' Attitudes Toward Medical Assistance in Dying · 2026 · DOI

• To solidify the theoretical framework developed in this study, future research should employ more granular measures of religiosity to explicitly test the mechanisms of sacred values and external locus of control. Specifically, Hoge’s (1972) Intrinsic Religious Motivation Scale could define the extent to which religion functions as an "ultimate" rather than "instrumental" motive. If intrinsic motivation predicts rigid opposition to MAiD, it would confirm that for these individuals the sanctity of life operates as a non-negotiable sacred value similar to moral conviction. Furthermore, Pargament et al.’s (1988) "Deferring" style of religious coping, which measures the active handing over of problem-solving responsibility to God, offers a direct operationalization of the external locus of morality. Using these scales would allow future studies to empirically verify if the hardening effect observed here is indeed driven by the theological surrender of control. Finally, future research should investigate the stability of these taboo trade-offs when contextual information is introduced. McGraw and Tetlock (2005) argue that even "morally corrosive" taboo trade-offs are subject to the reality constraint principle, where individuals actively seek to reframe a prohibited transaction into a more acceptable relational category to avoid identity threat. In the context of MAiD, Bloomer et al. (2024) found evidence of this flexibility, noting that even among religious groups with strict prohibitions against assisted dying, the specific context of "unbearable suffering" often ameliorated opposition. The current study’s survey did not specify the patient’s level of suffering, potentially capturing the "default" SACRED VALUES, MORAL CONVICTION, AND MAID 39 religious prohibition. Future studies should therefore test whether framing the request within the context of "unbearable suffering" moderates the interaction between religiosity and moral conviction, potentially softening the rigidity of the taboo trade-off by shifting the relational frame from divine authority to compassionate care.

  Moral Conviction, Religiosity, and Ethical Trade-offs in Medical Professionals' Attitudes Toward Medical Assistance in Dying · 2026 · DOI

• While the present systematic review provides important insights into ethical and medico-legal challenges in nursing practice, certain limitations should be acknowledged to ensure balanced interpretation of the findings. First, the review included only studies published in the English language. Consequently, relevant evidence published in other languages may not have been captured, particularly from regions where nursing ethics and medico-legal practices are influenced by distinct cultural and healthcare frameworks. This may have introduced a degree of language and publication bias. Second, considerable heterogeneity existed among the included studies in terms of study design, sample characteristics, clinical settings, and outcome assessment methods. Because of this methodological diversity, quantitative meta-analysis was not feasible, and the findings were synthesized narratively. Although narrative synthesis allowed broader conceptual interpretation, it may limit statistical comparability across studies. IJFMR260378424 Volume 8, Issue 3, May-June 2026 13 International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] Another important limitation relates to the predominance of cross-sectional and self-reported studies within the available literature. Ethical awareness, moral distress, and medico-legal practices were frequently assessed through self-administered questionnaires, which may be influenced by recall bias, social desirability bias, and subjective interpretation. Therefore, the reported levels of awareness and ethical competence should be interpreted cautiously. Additionally, many studies were conducted within specific institutional or regional settings, limiting the generalizability of findings across different healthcare systems. Ethical decision-making in nursing is strongly shaped by organizational culture, legal frameworks, resource availability, and sociocultural values; therefore, variations across countries and institutions are expected. The review also identified a relative scarcity of longitudinal and interventional research examining long- term outcomes of ethics education, institutional reforms, and policy-based interventions. Most available evidence remains descriptive in nature, highlighting the need for stronger analytical and implementation- oriented research in this field. Despite these limitations, the review synthesizes a broad and internationally relevant body of evidence that contributes meaningfully to the understanding of ethical governance, professional accountability, and medico-legal preparedness in nursing practice. The findings therefore provide a valuable foundation for future research, policy development, and institutional strengthening.

  Ethical Governance, Medico-Legal Accountability, and Clinical Decision-Making in Nursing Practice: A Systematic Review of Awareness, Ethical Challenges, and Institutional Determinants · 2026 · DOI

• Several limitations should also be acknowledged. Convenience sampling may have introduced selection bias and may limit represen- tativeness. The study also relied on self-reported data, which raises the possibility of response bias. In addition, the proportion of postgradu- ate participants was relatively small, which may limit subgroup-level interpretation. Finally, because EFA and CFA were conducted on the remains necessary. same dataset, Furthermore, the present cross-sectional validation design does not allow conclusions about temporal or causal ordering between the identified components. Future longitudinal studies are therefore required to further examine the relationship between moral motiva- tion and action, thereby addressing the methodological limits of the present research. independent replication Visualization, Writing – review & editing. FT: Investigation, Software, Validation, Writing – review & editing. LW: Software, Writing – review & editing. YL: Methodology, Supervision, Writing – review & editing. KZ: Conceptualization, Supervision, Writing – original draft.

  Psychometric validation of the Chinese version of the ethical decision-making competence scale in mainland Chinese nursing students · 2026 · DOI

• A strength of this study was not only focus on different validation aspects but also its emphasis on the practical usability of the instrument by defining an expert-developed cut-off for high moral distress that can be used for targeted interventions. We also employed an index calculation method that better aligns with the structure of the MDS-R, which we consider to represent a formative measurement model. As such, the traditional approach to calculating mean scores, based on the assumption of unidimensionality, is not appropriate. Another strength was the use of cognitive interviews, which has the potential to reveal additional problems, such as issues with question design or usability that might otherwise have been overlooked. A limitation was the limited number of respondents in the cognitive interviews, which may affect the transferability of the findings. To limit this potential bias, experienced respondents were purposively sampled to gain a high information power20. These participants had up to 36 years of experience, were currently employed in a wide range of units across two different organisations, and most of them had experience working across other units throughout the years. The cross-sectional design prevented causal inferences, and future research employing longitudinal designs is needed to clarify the temporal and potentially reciprocal relationships between moral distress, burnout, and stress. In addition, the present validation work has defined boundaries that should be acknowledged. The instrument underwent substantial adaptation, which may affect content equivalence with the original MDS-R and limits direct comparability with studies using earlier versions. Moreover, several measurement properties typically evaluated in reflective models, such as internal consistency, factor structure, and measurement invariance, were not assessed, as they are not appropriate for a formative conceptualisation. Finally, the proposed cut-off for high moral distress is inherently normative, as it is based on expert judgement rather than empirical outcome-based calibration, highlighting the need for further studies to examine its generalisability, empirical grounding, and usefulness across different occupational groups and contexts.

  Measuring moral distress in Swedish maternal and neonatal healthcare: validation of an adapted MDS‑R and development of a criterion‑based index · 2026 · DOI

• Several limitations should be acknowledged. First, the cross- sectional design precludes causal inference; therefore, longitudi- nal and intervention-based studies are needed to clarify causal pathways and to examine changes in ethical decision-making con- fidence (EDMC) over time. Second, participants were recruited exclusively from hospitals in Guizhou Province, a region charac- terized by specific healthcare resource distribution patterns, orga- nizational structures, and sociocultural contexts. These contextual characteristics may differ from those of more economically devel- oped regions or other national healthcare systems, potentially limiting the external validity and international generalizability of the findings. Although core determinants identified in this study—such as moral resilience and hospital ethical climate—have demonstrated relevance in cross-cultural nursing research, their magnitude and underlying mechanisms may vary across institu- tional and cultural environments. Therefore, caution is warranted when extrapolating these findings beyond the study setting. Third, although thematic saturation was achieved, the relatively small qualitative sample may not fully capture the diversity of experi- ences among nurse leaders. In addition, the extremely small number of participants with graduate-level education (n = 5) lim- ited the stability and interpretability of education-related com- parisons; therefore, educational attainment was not treated as a robust explanatory factor in this study. Future research should adopt multicenter, large-scale, and cross-regional or cross-national mixed-methods designs to exam- ine the structural stability and contextual variability of EDMC across diverse healthcare systems. Longitudinal investigations are needed to explore the dynamic development of ethical confidence, and rigorously designed intervention studies should evaluate the effectiveness of targeted organizational and educational strategies. Furthermore, the development, cultural adaptation, and empirical validation of context-specific ethics training and institutional sup- port programs will be essential to advance evidence-based approaches for strengthening nurse leaders’ ethical decision-mak- ing confidence in varied healthcare environments. Future studies may also consider stratified sampling strategies to ensure adequate representation across educational levels and to enhance statistical power in subgroup analyses.

  Ethical decision-making confidence among nurse leaders: a mixed-methods study of determinants and ethical implications · 2026 · DOI

• This paper is a conceptual and interpretive review rather than an empirical study. It does not test causal hypotheses, quantify prevalence, or provide population level estimates of the phenomena discussed. The genealogy offered is selective and aims to clarify semantic shifts and institutional uptake, not to provide an exhaustive intellectual history of autonomy, authority, recognition, or duty. The interdisci- plinary synthesis is purposive rather than systematic, and relevant literatures may have been omitted, especially work that frames therapeutic culture, recognition politics, or plat- form governance in more positive or context dependent terms. Empirical studies are used illustratively to constrain speculation, but they are not appraised through formal sys- tematic review methods, and the evidentiary base varies across subtopics. Key constructs such as “cancel culture,” “authority,” and “duties” are contested and culturally vari- able, which limits generalizability across countries, politi- cal regimes, and institutional settings. Finally, the paper’s normative conclusions reflect a reconstructive philosophical stance and should be read as proposals for further debate and empirical investigation rather than as prescriptive pol- icy recommendations.

  A review of contemporary autonomy: ethics, authority, and the fragility of the late modern subject · 2026 · DOI

• The paper identifies a conceptual register mismatch: vulnerability operates in the register of possibility while vital needs operate in the register of necessity, yet Mackenzie assumes they jointly ground obligations. Vulnerability theorists must clarify how obligations can be grounded by features operating on different conceptual registers, or alternatively, reformulate vulnerability's conceptual status to align with the necessity-register of vital needs.

  Vulnerability as a normative concept: reviving the scepticism · 2026 · DOI

• The paper shows that both interest-based and consent-based conceptions of vulnerability are relational (vulnerable-to formulations) and fail to ground obligations independently. Theorists need to empirically or conceptually specify which particular features of ontological vulnerability (beyond its connection to neediness and dependency) carry normative weight in bioethical applications and how these features differ from susceptibility or risk framing.

  Vulnerability as a normative concept: reviving the scepticism · 2026 · DOI

• The weak sense of moral salience (as mere relevance) successfully avoids circularity but creates a new problem: vulnerability appears to do minimal normative work since the obligating force is displaced onto an independent principle P (e.g., attending to vital needs). Vulnerability theorists must demonstrate what substantive normative work vulnerability performs that is not already accomplished by principles like need-satisfaction or dependency-based care.

  Vulnerability as a normative concept: reviving the scepticism · 2026 · DOI

• The paper reveals that the strong sense of 'morally salient' leads to circular reasoning when applied to vulnerability as a foundational concept. Vulnerability theorists must develop an independent normative principle or meta-ethical framework that explains why and how ontological vulnerability generates obligations without presupposing the conclusion that vulnerability grounds obligations.

  Vulnerability as a normative concept: reviving the scepticism · 2026 · DOI

• The paper identifies a critical unresolved question about whether ontological vulnerability and dependency are functionally co-constitutive in the sense required to ground moral obligations concerning vital needs. Vulnerability theorists need to provide formal logical demonstration that functional co-constitution between vulnerability and dependency actually establishes vulnerability as foundational to needs-related moral obligations, rather than merely assuming this relationship.

  Vulnerability as a normative concept: reviving the scepticism · 2026 · DOI

• Despite increased attention to the ethics of CHIs during the COVID-19 pandemic, CHIs remain controversial, and there has been no in-depth treatment of CHIs through the lens of virtue ethics.

  Virtue ethics and the unsettled ethical questions in controlled human infection studies · 2024 · DOI

• Referring to real healthcare cases and legal regulations, this paper argues that these reasons should be evaluated either ex ante or ex post and defends novel conceptual claims that have not been analyzed in the debates on CO.

  Conscientious Objection in Healthcare: The Requirement of Justification, the Moral Threshold, and Military Refusals · 2023 · DOI

• We use contemporary end-of-life illness narratives-a resource that has not been analyzed with respect to autonomy-and show how they illustrate important Kantian themes, namely, the duty to know oneself, the interest in elaborating universalizable principles, and the emphasis on ideals as points of orientation that guide behavior without ever being fully realized.

  “Accompanied Only by My Thoughts”: A Kantian Perspective on Autonomy at the End of Life · 2022 · DOI

• Moreover, other instruments including moral distress risk scale (MDSR) and moral distress thermometer (MDT) should be further validated and utilized because it covered the gap missed by most instruments.

  Instruments for Detecting Moral Distress in Clinical Nurses: A Systematic Review · 2021 · DOI

• While principlism is presented as a practical approach offering structure for ethical quandaries without generating definitive solutions, the paper does not address how to resolve conflicts when the four core principles (beneficence, non-maleficence, autonomy, justice) are in direct opposition in specific clinical contexts or patient populations.

  Principles and ethics in medicine · 2020 · DOI

• The paper notes that consequentialism cannot distinguish between foreseen and intended consequences in medical decisions (using antibiotic treatment risk as an example), but provides no framework or decision-making algorithm for clinicians to systematically apply this distinction in real-world scenarios where multiple outcomes with varying probabilities are present.

  Principles and ethics in medicine · 2020 · DOI

• The paper discusses virtue ethics as aligning with traditional professional conduct models like the Hippocratic Oath and General Medical Council's Good Medical Practice guidelines, but does not specify empirical methods to assess whether virtuous character development in medical training actually produces better clinical outcomes or improved patient satisfaction compared to principle-based or consequentialist training approaches.

  Principles and ethics in medicine · 2020 · DOI

• The paper identifies that happiness and well-being in consequentialist medical ethics mean different things to different people, and the relationship between happiness and measurable health outcomes (health, wealth, intelligence, mobility) is far from straightforward. However, there is no empirical investigation into how to operationalize and measure happiness across diverse patient populations in clinical settings, particularly in terminal illness contexts where the paper notes cancer patients' happiness does not decline predictably as death approaches.

  Principles and ethics in medicine · 2020 · DOI

• The paper identifies that defensive medicine drives unnecessary test ordering but does not establish specific metrics for measuring the prevalence of defensive ordering in primary versus secondary care settings, or define threshold criteria for distinguishing evidence-valid care from defensive practice.

  Allocation of resources in medicine – a moral imperative for doctors as well · 2020 · DOI

Most-cited papers in Ethics in medical practice

• Moral Distress Among Healthcare Professionals: Report of an Institution‐Wide Survey · Journal of Nursing Scholarship · 2014 · 413 citations
• Epistemic Injustice and Illness · Journal of Applied Philosophy · 2016 · 302 citations
• Doctors’ and nurses’ perceptions of ethical problems in end‐of‐life decisions · Journal of Advanced Nursing · 2001 · 253 citations
• Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP · Journal of Religion and Health · 2020 · 206 citations
• Moral distress within neonatal and paediatric intensive care units: a systematic review · Archives of Disease in Childhood · 2016 · 191 citations
• The relationship between moral sensitivity and professional values and ethical decision-making in nursing students · Nurse Education Today · 2021 · 136 citations
• Professional ethics in nursing: an integrative review · Journal of Advanced Nursing · 2015 · 127 citations
• Interventions to mitigate moral distress: A systematic review of the literature · International Journal of Nursing Studies · 2021 · 125 citations
• Nurses’ responses to ethical dilemmas in nursing practice: meta‐analysis · Journal of Advanced Nursing · 2008 · 124 citations
• The need for health AI ethics in medical school education · Advances in Health Sciences Education · 2021 · 111 citations

Most recent work

• What Does Moral Agency Mean for Nurses in the Era of Artificial Intelligence? · The Hastings Center Report · 2026
• A Confucian Perspective on Public Health Ethics · Bioethics · 2026
• Narrative ethics as an eldering paradigm · Family Court Review · 2026
• Individual and Systemic Etiologies and Interventions to Address Moral Distress, Moral Crescendo, Secondary Traumatic Stress, and Burnout in Emergency Nurses · Nursing Clinics of North America · 2026
• Ethical transgressions by registered psychologists in South Africa during the period 2014–2023 · South African Journal of Psychology · 2026
• The Because/in Order to Distinction and the Ethics of Euthanasia: Demonstrating that Death Is Not an Unconditional Evil for Double Effect Analysis · Journal of Applied Philosophy · 2026
• Defending the soul of Nursing · Nursing · 2026
• In respect for human dignity · Nursing · 2026
• “It’s Shaking Your Entire Construction as a Human Being”: A Qualitative Analysis on Epistemic Injustice and Medical Gaslighting Consequences in Patients Living with Chronic Pain · The Journal of Medicine and Philosophy A Forum for Bioethics and Philosophy of Medicine · 2026
• Ethics beyond the ethics board: field research in light of the local turn · Peacebuilding · 2026

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