A situation in which an individual feels compelled to

make a choice between two or more actions that he or

she can reasonably and morally justify, or when
evidence or an arguments are inconclusive, is called
an ethical dilemma (Beauchamp&Childress,2001;McConnell,2002).
One action must be chosen because performing both
actions would be impossible.
Ethical Dilemmas are usually described in terms of
right or wrong, duty or obligation, rights or
responsibilities, and good or bad. Ethical dilemmas
are commonly identified by the question,” What
should be done?”
 Most dilemmas can be identified according to the
following classifications:

• Dilemmas of Beneficence-dilemma that involve

deciding what is good as opposed to what its harmful.

• Dilemmas of autonomy- those that involve deciding

what course of action maximize the patient's right of
self determination.
 
• Dilemmas of justice- dilemmas that involve dividing
limited health care resources fairly
• Dilemmas of fidelity- those that are involve
honoring promises
 
• Dilemmas of non maleficence- dilemmas that
involve the avoidance of harm

• Dilemmas of confidentiality- those that involve

respecting privileged information

• Dilemmas of veracity- dilemmas that involve

telling or concealing the truth
Growing awareness of ethical problems has occurred
largely because of (a) social and technological
changes and (b) conflicting loyalties and obligations.
 Social changes, such as the women’s movement. The
large number of people without health insurance, the
high cost of health care.

 Technology creates new issues that did not exist in

earlier times. Before monitors, respirators, and
parenteral feedings, there was no question about
whether to ‘’ allow’’ an 800- gram premature infant
to die.
Before organ transplantation , death did not require a
legal definition that might still permit viable tissues
to be removed and given to other living persons.
Advances in the ability to decode and control the
growth of tissues through gene manipulation present
new potential ethical dilemmas related to cloning
organisms and altering the course of hereditary
disease and biological characteristics. Today, with
treatment that can prolong and enhance biologic life,
these questions arise: should we do what we know we
can?
Health workers experience conflicts among their
loyalties and obligations to clients, families, primary
care providers, employing institutions. Client needs
may conflict with institutional policies, primary care
provider preferences, needs of the client’s family, or
even laws of the state. However, it is not always easy
to determine which action best serves the client’s
needs.
 Responsible ethical reasoning is rational and
systematic. It should be based on ethical principles
and codes rather than on emotions, intuition, fixed
policies, or precedent that is, an earlier similar
occurrence).
Two decision – making models
1- Thompson and Thompson (1985)
 Review the situation to determine health problems,
decision needs, ethical components, and key
individuals.
 Gather additional information to clarify the situation
 Identify the ethical issues in the situation.
 Define personal and professional moral positions.
 Identify moral positions of key individuals involved
 Identify value conflicts, if any
 Determine who should make the decision
 Identify range of actions with anticipated outcomes.
 Decide on a course of action and carry it out.
 Evaluate / review results of decision / action.
2- Cassells and Redman (1989)
 Identify the moral aspects of care
 Gather relevant facts related to a moral issue.
 Clarify and apply personal values
 Understand ethical theories and principles
 Utilize competent interdisciplinary resources
 Propose alternative actions.
 Apply codes of ethics to help guide actions
 Choose and implement resolutive action.
 Participate actively in resolving the issue
 Apply state and federal laws governing practice.
 Evaluate the resolutive action taken
A good decision is one that is in the client’s best
interest and at the same time preserves the integrity
of all involved. Health workers have ethical
obligations to their clients, to the agency that
employs them, and to primary care providers.
Therefore, midwives must weigh competing factors
when making ethical decisions.
 Maximize the client’s well – being
 Balance the client’s need for autonomy with family
member’s responsibilities for the client’s well – being
 Support each family member and enhance the
family support system.
 Carry out hospital policies.
 Protect other client’s well – being
 Protect the standards of care.
The health professional may feel torn between
obligations to the client, the family, and the
employer. What is in the client’s best interest may be
contrary to the health professional personal belief
system. In settings in which ethical issues arise
frequently, doctors should establish support systems
such as team conferences and use of counseling
professionals to allow expression of their feelings.
  Active decisions-ethical decisions and moral
judgments that lead directly to actions and bring
about changes

  Passive decisions- decisions that deny , delay, or

avoid action and maintain the status quo by denying
or shifting responsibility to avoid changes
• Programmed decisions- decisions that use precedents,
established guidelines, procedures, and rules to resolve
anticipated, routine, expected types of moral dilemmas

• Non-programmed decisions- decisions that require a unique

response to complex and unexpected moral dilemmas.
Process for resolving ethical problems:

 recognition of ethical dilemma

 Gathering relevant factual information

 Clarify the personal context of the ethical dilemma

 Identify and clarify the ethical concept

 Construct and evaluate arguments for each issue.

 Take action. (Make decision)
Ethical decision making is a skill that can be learned,
based on understanding of underlying ethical
principles, ethical theories or systems, a decision
making model, and the ICM of Ethics.