Ethical Decision Making

Morality and Moral Values

Personal morality
Societal morality
Group morality

Decisions and Actions

Rules and Codes

Moral Principles

Ethical Theories

Moral Philosophy

Moral Philosophy

Teleological: the end justifies the means

Deontological: the means need to be

carefully weighed without primary concern
for the outcome

Ethical Theories
Descriptive Ethics: Moral system of a group
or culture
Normative Ethics: Moral system used to
make moral decisions
Bioethics: the application of ethics to health
care

Ethical Principles
Nonmaleficence
Beneficence
Autonomy
Justice
Distributive
Compensatory (and retributive)
Procedural

Rules and Codes

Fidelity: being faithful to ones clients,
employer and colleagues
Confidentiality (privacy): keeping nonrelevant information private
Veracity: telling the truth; not lying
APTA Code of Ethics
FIU Student Code of Standards

The Nature of Ethical Principles*

Fundamentalism:
the philosophical
stance that ethical
principles are
universal

Multiculturalism: the
anthropological stance
that ethical principles
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)459468.

Possible Cultural Differences*

Individualism Communitarianism
Autonomy . Family decision-making
Individual liberty .... Social/common good
The individual .... The collective
Individual rights .. Personal virtues
Individual development .... Family and filial piety
Contract .... Trust
Self-determination ..... Self-examination
Freedom .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
individualism lead to
valuing individual
autonomy
Informed consent &
advanced directives

The individual as part

of the larger whole
values group cohesion

Porous social groups

Group decides if
patient is told & what
to do
Social groups resist
outsiders

* Davis AJ. Global influence of American nursing: some ethical

issues. Nursing Ethics. 1999;6(2):118-125.

The Realm-Individual ProcessSituation (RIPS) Model of

Ethical Decision Making
A formalized approach to reflection and
analysis of morality

Four Step Process

Step I: Recognize and define the ethical
issue (realm, individual process and
situation)
Step II: Reflect
Step III: Decide the right thing to do
Step IV: Implement, evaluate and reassess

Components of the RIPS Model

Realm

Individual Process Ethical Situation

Individual
Institutional/
Organizational
Societal

Moral Sensitivity
Moral Judgment
Moral Motivation
Moral Courage

Problem or issue
Temptation
Distress
Dilemma
Silence

Realm

Individual realm: concerned with the good of the

patient/client and focuses on rights, duties,
relationships and behaviors between individuals
Institutional/organizational realm: concerned with
the good of the organization and focuses on
structures and systems that will facilitate their
goals

Societal realm: concerned with the common good

Individual Process

Moral sensitivity: recognizing, interpreting and

framing ethical situations
Moral judgment: deciding between right and
wrong actions; considering ethical principles
(autonomy, etc), then selecting and applying them
Moral motivation: prioritizing ethical values over
financial gain or self-interest
Moral courage: implementing the chosen ethical
action, even though doing so may cause adversity

Ethical Situation

Problem or issue: a situation in which important

moral values are being challenged
Temptation: a situation in which a choice must be
made between a right action and a wrong action,
where the wrong action may benefit the decisionmaker in some way
Silence: key parties realize ethical values are being
challenged, but do nothing
Distress
Dilemma

Ethical Distress

Ethical distress: there is a structural barrier

to doing the right thing
Type A: There is a barrier keeping you from
doing what you know is right
Type B: There is a barrier because something is
wrong, but you are not sure what that
something is

Ethical Dilemma
There are two (or more) correct courses of
action that cannot both be followed.
You are doing something right, and also
something wrong.
Most often involve ethical conduct (e.g.
honoring autonomy vs. preventing harm).
May involve conflicting traits of character
(e.g. honesty vs. compassion)

Step II: Reflect

What are the relevant facts and contextual

information?
Who are the major stakeholders?
What are the potential consequences, intended or
unintended?
What are the relevant laws, duties, and ethical
principles?
What professional guidance do we have?
What do the right vs. wrong tests suggest you
should do?

Right vs. Wrong

The legal test: Did anyone do anything illegal?

The stench test: Does the situation smell wrong?
Publicity (the front page test): Would any of the parties
involved be embarrassed by the truth coming out?
Universality (the mom test): What would your mom do?
Is this the right thing to do regardless of whos involved?
The ethics test: Do the Code of Ethics, the Guide to
Professional Conduct, or Professionalism in Physical
Therapy: Core Values, say anything about this situation?

Cultural Issues

Explicitly acknowledge patients cultural norms,

beliefs and values
Locate the patients individual beliefs
Be explicit about the process of decision-making
that generally guides your actions
Come to an agreement between all parties (perhaps
including the family) on what 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
want every one else to follow
(deontological)
Ends-based: Do whatever produces the
greatest good for the greatest number
(teleological)
Care-based: Do onto others as you would
have them do onto you (the golden rule)

Step IV: Implement, Evaluate

and Reassess

Implement: moral courage (role-play, prepare,

imagine)
Evaluate and reassess

Did things turn out the way you expected?

What did you do well? Not so well?
What were the most challenging aspects of this
situation?
How did this situation compare with others you have
encountered or read about?
How will this experience make you a better
professional?