Background: Studies have explored community pharmacy ethical dilemmas; however, limited research exists on hospital pharmacy ethical issues and pharmacists’ ethical decision-making processes. Research exploring this is timely, considering developments in hospital pharmacy practices, new hospital pharmacist roles, and evolving responsibilities. Aim/objectives: To explore hospital pharmacists’ ethical decision-making and processes for managing ethical challenges in the context of evolving Australian hospital pharmacy practices. Methods: Face-to-face semi-structured interviews with 20 purposively-selected hospital pharmacists from four Queensland Health hospitals. An interview guide with 11 open-ended questions and prompts was developed, validated, and trialed. Pharmacists who consented received the guide prior to interviews. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo 12 to facilitate coding and thematic analysis. Results: Participants were interviewed January to April 2019; median interview duration was 17.45 min. Data saturation was reached. Participants’ experiences ranged from junior level pharmacists to senior management positions, in clinical and non-clinical roles. Emerging themes were: 1) influences on the development of ethical decision-making skills, 2) ethical decision-making is an integral part of the hospital pharmacist’s role, and 3) institutional requirements and settings impact on ethical exposure. A wide range of contemporary ethical issues unique to hospital pharmacy practice, mostly involving complex medication management safety, supply, and cost scenarios, were identified. Junior pharmacists indicated they would benefit from additional training, mentorship, and availability of hospital-specific targeted ethics resources. Conclusion: The findings highlighted that hospital pharmacists are regularly faced with ethical issues unique to the hospital pharmacy practice context. Application of sound and structured ethical reasoning and decision-making is, therefore, required in this setting. Participants identified many interrelated factors that impacted their ethical reasoning and behaviour. This study identified gaps that, once addressed, will better support ethical reasoning in hospital pharmacy settings.