Ethical Decision Making

Morality and Moral Values

Personal moralityPersonal morality Societal moralitySocietal morality Group moralityGroup morality

Decisions and Actions

Rules and Codes

Moral Principles

Ethical Theories

Moral Philosophy

Moral Philosophy

Teleological: the end justifies the meansTeleological: the end justifies the means

Deontological: the means need to be Deontological: the means need to be carefully weighed without primary concern carefully weighed without primary concern for the outcomefor the outcome

Ethical Theories

Descriptive Ethics: Moral system of a group Descriptive Ethics: Moral system of a group or cultureor culture

Normative Ethics: Moral system used to Normative Ethics: Moral system used to make moral decisionsmake moral decisions

Bioethics: the application of ethics to health Bioethics: the application of ethics to health carecare

Ethical Principles

NonmaleficenceNonmaleficence BeneficenceBeneficence AutonomyAutonomy JusticeJustice

DistributiveDistributive Compensatory (and retributive)Compensatory (and retributive) ProceduralProcedural

Rules and Codes

Fidelity: being faithful to one’s clients, Fidelity: being faithful to one’s clients, employer and colleaguesemployer and colleagues

Confidentiality (privacy): keeping non-Confidentiality (privacy): keeping non-relevant information privaterelevant information private

Veracity: telling the truth; not lyingVeracity: telling the truth; not lying APTA Code of EthicsAPTA Code of Ethics FIU Student Code of StandardsFIU Student Code of Standards

The Nature of Ethical Principles*

FundamentalismFundamentalism: : the philosophical the philosophical stance that ethical stance that ethical principles are principles are universaluniversal

MulticulturalismMulticulturalism: the : the anthropological stance anthropological stance that ethical principles that ethical principles are “culturally-bound”are “culturally-bound”

* Crigger NJ, Holcomb L, Weiss J. Fundamentalism, multiculturalism and problems of conducting research with populations in developing nations. Nursing Ethics. 2001;8(5)459-468.

Possible Cultural Differences*

Individualism ………………………… CommunitarianismIndividualism ………………………… CommunitarianismAutonomy …………………….… Family decision-makingAutonomy …………………….… Family decision-makingIndividual liberty …………….……... Social/common goodIndividual liberty …………….……... Social/common goodThe individual ………………..……..……… The collectiveThe individual ………………..……..……… The collectiveIndividual rights ………………..………… Personal virtuesIndividual rights ………………..………… Personal virtuesIndividual development ..………..… Family and filial pietyIndividual development ..………..… Family and filial pietyContract …………………………...……….………… TrustContract …………………………...……….………… TrustSelf-determination …………………...….. Self-Self-determination …………………...….. Self-

examinationexaminationFreedom …………………………….…Duty and obligationFreedom …………………………….…Duty and obligation

*Nie J-B. The plurality of Chinese and American medical moralities: Toward an interpretive cross-cultural bioethics. Kennedy Institute of Ethics Journal. 2000;10(3):239-260.

Contrasting Norms, Cultural Beliefs and Values* Self-reliance and Self-reliance and

individualism lead to individualism lead to valuing individual valuing individual autonomyautonomy

Informed consent & Informed consent & advanced directivesadvanced directives

Porous social groupsPorous social groups

The individual as part The individual as part of the larger whole of the larger whole values group cohesionvalues group cohesion

Group decides if Group decides if patient is told & what patient is told & what to doto do

Social groups resist Social groups resist outsidersoutsiders

* Davis AJ. Global influence of American nursing: some ethical issues. Nursing Ethics. 1999;6(2):118-125.

The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision Making

A formalized approach to reflection and A formalized approach to reflection and analysis of moralityanalysis of morality

Four Step Process

Step I: Recognize and define the ethical Step I: Recognize and define the ethical issue (realm, individual process and issue (realm, individual process and situation)situation)

Step II: ReflectStep II: Reflect Step III: Decide the right thing to doStep III: Decide the right thing to do Step IV: Implement, evaluate and reassessStep IV: Implement, evaluate and reassess

Components of the RIPS Model

RealmRealm Individual ProcessIndividual Process Ethical SituationEthical Situation

IndividualIndividual

Institutional/Institutional/

OrganizationalOrganizational

SocietalSocietal

Moral SensitivityMoral Sensitivity

Moral JudgmentMoral Judgment

Moral MotivationMoral Motivation

Moral CourageMoral Courage

Problem or issueProblem or issue

TemptationTemptation

DistressDistress

DilemmaDilemma

SilenceSilence

Realm

Individual realm: concerned with the good of the Individual realm: concerned with the good of the patient/client and focuses on rights, duties, patient/client and focuses on rights, duties, relationships and behaviors between individualsrelationships and behaviors between individuals

Institutional/organizational realm: concerned with Institutional/organizational realm: concerned with the good of the organization and focuses on the good of the organization and focuses on structures and systems that will facilitate their structures and systems that will facilitate their goalsgoals

Societal realm:Societal realm: concerned with the common goodconcerned with the common good

Individual Process

Moral sensitivity: recognizing, interpreting and Moral sensitivity: recognizing, interpreting and framing ethical situationsframing ethical situations

Moral judgment: deciding between right and Moral judgment: deciding between right and wrong actions; considering ethical principles wrong actions; considering ethical principles (autonomy, etc), then selecting and applying them(autonomy, etc), then selecting and applying them

Moral motivation: prioritizing ethical values over Moral motivation: prioritizing ethical values over financial gain or self-interestfinancial gain or self-interest

Moral courage:Moral courage: implementing the chosen ethical implementing the chosen ethical action, even though doing so may cause adversityaction, even though doing so may cause adversity

Ethical Situation

Problem or issue: a situation in which important Problem or issue: a situation in which important moral values are being challengedmoral values are being challenged

Temptation: a situation in which a choice must be Temptation: a situation in which a choice must be made between a right action and a wrong action, made between a right action and a wrong action, where the wrong action may benefit the decision-where the wrong action may benefit the decision-maker in some waymaker in some way

Silence: key parties realize ethical values are being Silence: key parties realize ethical values are being challenged, but do nothingchallenged, but do nothing

DistressDistress DilemmaDilemma

Ethical Distress

Ethical distress: there is a structural barrier Ethical distress: there is a structural barrier to doing the right thingto doing the right thing Type A: There is a barrier keeping you from Type A: There is a barrier keeping you from

doing what you know is rightdoing what you know is right Type B: There is a barrier because something is Type B: There is a barrier because something is

wrong, but you are not sure what that wrong, but you are not sure what that something issomething is

Ethical Dilemma

There are two (or more) correct courses of There are two (or more) correct courses of action that cannot both be followed.action that cannot both be followed.

You are doing something right, and also You are doing something right, and also something wrong.something wrong.

Most often involve ethical conduct (e.g. Most often involve ethical conduct (e.g. honoring autonomy vs. preventing harm).honoring autonomy vs. preventing harm).

May involve conflicting traits of character May involve conflicting traits of character (e.g. honesty vs. compassion)(e.g. honesty vs. compassion)

Step II: Reflect

What are the relevant facts and contextual What are the relevant facts and contextual information?information?

Who are the major stakeholders?Who are the major stakeholders? What are the potential consequences, intended or What are the potential consequences, intended or

unintended?unintended? What are the relevant laws, duties, and ethical What are the relevant laws, duties, and ethical

principles?principles? What professional guidance do we have?What professional guidance do we have? What do the “right vs. wrong” tests suggest you What do the “right vs. wrong” tests suggest you

should do?should do?

Right vs. Wrong

The legal test: Did anyone do anything illegal?The legal test: Did anyone do anything illegal? The “stench test”: Does the situation “smell” wrong?The “stench test”: Does the situation “smell” wrong? Publicity (the “front page test”): Would any of the parties Publicity (the “front page test”): Would any of the parties

involved be embarrassed by the truth coming out? involved be embarrassed by the truth coming out? Universality (the “mom test”): What would your mom do? Universality (the “mom test”): What would your mom do?

Is this the right thing to do regardless of who’s involved?Is this the right thing to do regardless of who’s involved? The ethics test: Do the The ethics test: Do the Code of EthicsCode of Ethics, the , the Guide to Guide to

Professional ConductProfessional Conduct, or , or Professionalism in Physical Professionalism in Physical Therapy: Core ValuesTherapy: Core Values, say anything about this situation?, say anything about this situation?

Cultural Issues

Explicitly acknowledge patient’s cultural norms, Explicitly acknowledge patient’s cultural norms, beliefs and values beliefs and values

Locate the patient’s individual beliefsLocate the patient’s individual beliefs Be explicit about the process of decision-making Be explicit about the process of decision-making

that generally guides your actionsthat generally guides your actions Come to an agreement between all parties Come to an agreement between all parties

(perhaps including the family) on what (perhaps including the family) on what information will be given and to whom.information will be given and to whom.

Irvine R, McPhee J, Kerridge IH. The challenge of cultural and ethical pluralism to medical practice. MJA. 2002;176:175-176.

Step III: Decide What To Do

Rule-based: Follow only the principle you Rule-based: Follow only the principle you want every one else to follow want every one else to follow (deontological)(deontological)

Ends-based: Do whatever produces the Ends-based: Do whatever produces the greatest good for the greatest number greatest good for the greatest number (teleological)(teleological)

Care-based: Do onto others as you would Care-based: Do onto others as you would have them do onto you (the “golden rule”)have them do onto you (the “golden rule”)

Step IV: Implement, Evaluate and Reassess Implement: moral courage (role-play, prepare, Implement: moral courage (role-play, prepare,

imagine)imagine) Evaluate and reassessEvaluate and reassess

Did things turn out the way you expected?Did things turn out the way you expected? What did you do well? Not so well?What did you do well? Not so well? What were the most challenging aspects of this What were the most challenging aspects of this

situation?situation? How did this situation compare with others you have How did this situation compare with others you have

encountered or read about?encountered or read about? How will this experience make you a better How will this experience make you a better

professional?professional?