Ethical Decision-Making

Process
Josephine D. Lorica
 Why ethical decision-making?

• Ethical decision making is required when the healthcare executive

must address a conflict or uncertainty regarding competing values,
such as personal, organizational, professional and societal values
• Healthcare executives have a responsibility to address the growing
number of complex ethical dilemmas they are facing, but they
cannot and should not make such decisions alone or without a
sound decision-making process. 
• The application of a systematic decision-making process can serve
as a useful tool for executives and others in addressing ethically
challenging situations.
Factors

• Many factors have contributed to the growing concern in

healthcare organizations over ethical issues, including
• issues of access and affordability,
• quality,
• value-based care,
• patient safety,
• mergers and acquisitions,
• financial and other resource constraints, and
• advances in medical technology that complicate decision making
near the end of life.
What is necessary?

• have resources that may include ethics committees, ethics

consultation services, and written policies, procedures and
guidelines to assist them with the ethics decision-making process.
• With these organizational resources and guidelines in place,
conflicting interests involving patients, families, caregivers, the
organization, payors and the community can be thoughtfully and
appropriately reviewed in a timely manner (American College of
Healthcare Executive, n.d.)
So?

• Ethical decisions made by health care workers are shaped by the

decision maker and the process used to resolve ethical dilemmas
• although systematic guidelines for resolving ethical dilemmas offer
health care workers a logical approach to the decision-making
sequence, it is inevitable that discretionary judgments will condition
the ultimate choice of action.
• Health care workers are influenced by professional roles, practice
experiences, individualized perspectives, personal preferences,
motivations, and attitudes (Mattison, 2000)
How?

• Through reflective self-awareness health care workers can

recognize their value preferences and be alert to the ways in which
these values unknowingly influence the resolution of ethical
dilemmas.
• Understanding which values or ethical principles were given priority
from among competing alternatives can inform health care workers
about their value patterning.
Ethical Decision-Making

• Ethical decision-making refers to the process of evaluating and choosing

among alternatives in a manner consistent with ethical principles. In making
ethical decisions, it is necessary to perceive and eliminate unethical options
and select the best ethical alternative. (Josephson Institute of Ethics, 2002).
• The process of making ethical decisions requires:
• Commitment: The desire to do the right thing regardless of the cost
• Consciousness: The awareness to act consistently and apply moral
convictions to daily behavior
• Competency: The ability to collect and evaluate information, develop
alternatives, and foresee potential consequences and risks
• Good decisions are both ethical and effective:
• Ethical decisions generate and sustain trust; demonstrate respect,
responsibility, fairness and caring; and are consistent with good citizenship.
These behaviors provide a foundation for making better decisions by setting
the ground rules for our behavior.
• Effective decisions are effective if they accomplish what we want
accomplished and if they advance our purposes. A choice that produces
unintended and undesirable results is ineffective. The key to making effective
decisions is to think about choices in terms of their ability to accomplish our
most important goals. This means we have to understand the difference
between immediate and short-term goals and longer-range goals.
"Character-Based Decision-Making Model“(
Josephson Institute of Ethics)
• three steps:
1.All decisions must take into account and reflect a concern for the interests and well being of all affected
individuals ("stakeholders").The underlying principle here is the Golden Rule — help when you can, avoid harm
when you can.
2.Ethical values and principles always take precedence over nonethical ones.Ethical values are morally superior to
nonethical ones. When faced with a clear choice between such values, the ethical person should always choose to
follow ethical principles.
3.Perceiving the difference between ethical and nonethical values can be difficult. This situation often occurs when
people perceive a clash between what they want or "need" and ethical principles that might deny these desires. If
some rationalization begins to occur, this situation is probably present.
4.It is ethically proper to violate an ethical principle only when it is clearly necessary to advance another true
ethical principle, which, according to the decision-maker's conscience, will produce the greatest balance of good
in the long run.Some decisions will require you to prioritize and to choose between competing ethical values and
principles when it is clearly necessary to do so because the only viable options require the sacrifice of one ethical
value over another ethical value. When this is the case, the decision-maker should act in a way that will create the
greatest amount of good and the least amount of harm to the greatest number of people.
Veatch’s Framework for Ethical Analysis

1. Gather all the facts to be sure an ethical dilemma actually exists

2. Determine the moral rules of the situation (i.e. level of confidentiality and consent)
3. Apply the 6 ethical principles: Beneficence, justice, veracity, fidelity, autonomy,
non-maleficence (BJVFAN)
4. Apply one of the three ethical theories: Teleological Theory (Act Utilitarianism),
Deontological Theory (Kantian Theory) and Rule Utilitarianism
Process of Ethical Decision-making

1. Ask “What is the ethical question?”

- In identifying the ethical question, the health care professional needs to
look for the “shoulds”
- These “shoulds” are the normative questions )what should or ought to
happen according to norms or standards) as opposed to description
questions ( what actually happens)
- These “shoulds””relate to your duties and obligations as a professional
- Key distinguishing feature of ethical “shoulds” – they are concerned
with the well-being of others and are not self-interested or self-directed
Process of Ethical Decision-making

2. As your first reaction to the case – “What is my ‘gut’ reaction? “What is my ‘gut
telling me to do on emotive level?
- Essential – need to identify your own values, assumptions and biases, and then set
them aside to critically analyze the situation

3. Gather relevant facts - both the known and those that you need to gather
- Good ethics begins with good facts
- Proceed if you consider why you want to know something and how will it change
your analysis
- If certain facts as unclear- assume one set for analysis then change the fcats to see
if your analysis would change
Process of Ethical Decision-making

4. Ask “What are the values at stake in the scenario?”

- Consider values from various perspectives – who are the
stakeholder? What is their perspective?
- Stakeholder – is someone who will be affected by the decision to
be made.
- The patient, the nurse and the physician, the parents, other
health care workers
Process of Ethical Decision-making

5. Ask “What are the options in this case?”

- Specifically what could the nurse and resident physician do in this scenario?

6. Ask “What should I do?”, “What do I think is the best option based on the
core values of the stakeholders?”

7. Ask “What justifies this choice?”

- Provide reasons to support your decisions based on values at stake
- This includes the ethical theories and principles
Process of Ethical Decision-making

8. Ask “How could this ethical problem have been prevented?” “Are
there any systemic changes that could be made to prevent this
problem from happening again?”
Current Ethical Approaches

Analysis of Principles
- Use of the principles of bioethics in understanding ethical issues

Analysis of rights
- Right – is an especially powerful moral claim that others are
obligated to respect
- Considering – a rights to life, right to die and a right to health care
Current Ethical Approaches

Ethics of care
- “doing ethics”
- Emphasize the importance of focusing on the patient and the
professional in the context of his or her relationships
- Considers emotional commitment and willingness of individuals in
a relationship to act unselfishly for the benefit of others
- More than principle-based approach
Current Ethical Approaches

Virtue-based Ethics
- Emphasizes the agents who perform actions and make choices
- Virtue- is a habit of behaving in a good way
- this approach examines feelings, motivations and duties
- examines not only actions, but the individuals’ character as well
References

Ethical Decision-making for Health Care Executives

• https://www.ache.org/about-ache/our-story/our-commitments/e
thics/ache-code-of-ethics/ethical-decision-making-for-healthcare-
executives