ETHICAL DECISION MAKING

Overview
• Everyone makes decisions as part of everyday
living.
• Some decision are done routinely and some
through deliberation
• As medical profession we decide matters related
to management of care, institutional policy, or
when to collaborate or initiate referrals
Moral Uncertainty
• Occurs when we sense that there is a moral
problem, but are not sure of the morally correct
action, when we are unsure what the moral
principles or values apply, or when we are
unable to define the moral problem
• Ex: practitioner caring for an old patients
problem who is somewhat neglected, with little
attention being given to the patient’s problem.
The practitioner feels dissatisfied with the
patient’s treatment, but is unable to pinpoint the
nature and cause of inadequacy.
Moral/Ethical dilemma
• Dilemma
▫ Exist when a difficult problem seems to have no
satisfactory solution or when all solutions to a
problem appear to be equally favorable
• Ethical dilemma
▫ Occurs when there are conflicting moral claims
• 2 ways presenting dilemma
1. A conflict can be experienced when there is
evidence to indicate that a certain act is morally
right and evidence to indicate that the act is
morally wrong, but no evidence is conclusive.
• Ex. Terminally ill patient. Most would think it is
morally right to preserve life, many would
believe it is morally wrong to prolong suffering.
2. When the agent believes that one or more moral
norms exist to support another course of action,
and the two actions are mutually exclusive
• Ex. When they must decide who gets the critical
care bed. Should they make the decision relative
to who is deserving, who arrive first, who can
pay or who has the best chance for survival.
Practical dilemma
• Situations presents themselves in which moral
claims compete with nonmoral claims
• Nonmoral claims- can be often identified as
claims of self-interest
• Ex. Mother that is on duty as health care
provider that promised to her children to take
them to the circus.
Moral Distress
• Occurs when situation that present moral
problems which seem to have clear solutions, yet
they are unable to follow their moral beliefs
because of institutional or other restraints
Moral Outrage
• Occurs when someone else in the health care
setting performs an act the other health care
provider believes to be immoral
• Ex. In charge healthcare provider over hears a
conversation.

Anybody can become angry – that is easy, but to be angry with the right
person and to the right degree and at the right time and for the right
purpose, and in the right way – that is not within everybody’s power and
is not easy. –Aristotle
Ethical Decision Making
• Giving good reasons in science is called
explanation while giving good reason in ethics
is called moral justification
• Scientific process of explanation
▫ Observation
▫ Hypothesis
▫ Law
▫ Theory
• Moral justification process
▫ Assessed ethical dilemma
▫ Rule
▫ Principle
▫ Theory
• Factors:
▫ Strong knowledge to the societal rules, ethical
principles, theories, professional codes and
standards.
Emotions and Ethical Decisions
• Emotions describe as personal signals providing
information regarding both inner processes and
interactions with the environment
• It is important to appreciate not only what you
think about what is right or wrong but also what
you feel in relation to the circumstances and
decision to be made
• Goal: to have head and heart in harmony as the
decision is made
Process of Ethical Decision Making
1. Gather data and identify conflicting moral claims
▫ Gather information or facts in order to clarify issues
▫ Identification of the conflicting moral claims that
constitute ethical dilemmas
▫ Examine the situation for evidence of conflicting
obligations, principles, duties, rights, loyalties,
values or beliefs
▫ Pay attention to societal, religious and cultural
values and beliefs
• What makes this situation an ethical problem?
Are there conflicting obligations, duties,
principles, rights, loyalties, values or beliefs?
• What are the issues?
• What fact seems most important?
• What emotions have an impact?
• What are the gaps in information at this time?
2. Identify Key Participants
▫ Identify the persons involved in the decision making
process and delineate each person’s role
• Who is legitimately empowered to make this
decision?
• Who is affected and how?
• What is the level of competence of the person most
affected in relation to the decision to be made?
• What are the rights, duties, authority, context, and
capabilities of participants
3. Determine Moral Perspective and Phase of
Moral Development of Key Participants
▫ Knowledge of moral development and ethical
theory may provide a helpful framework for
understanding participants and their perspectives
and responses in the process
▫ It is valuable to recognize whether the principal
decision maker is at a developmental level in
which choices reflect a desire to please others or
seeking for approval
• Do participants think in terms of duties or rights?
• Do the parties involved exhibit similar or different
moral perspectives?
• Where is the common ground? The differences?
• What principles are important to each person
involved?
• What emotions are evident within the interaction
and with each person involved?
• What is the level of moral development of the
participants?
4. Determine Desired Outcomes
▫ Identifying the desired outcomes and their
potential consequences is a substantial step in the
decision making process
▫ Clarifying the outcomes and their anticipated
consequences enhances the understanding of
options and alternatives
• How does each party describe the circumstances
of the outcome?
• What are the consequences of the desired
outcomes?
• What outcomes are unacceptable to one or all
involved?
5. Identify Options
▫ Participants should identify possible options for
actions
▫ It is critical to eliminate all unacceptable
alternatives and begin the process of listing,
weighing, ranking and prioritizing those that are
found to be acceptable
▫ Once the selection is made, the decision makers
must be willing to act upon the choice
• What option emerge through the assessment
process?
• How do the alternatives fit the lifestyle and values
of the person affected?
• What are legal considerations of the various
options?
• What alternatives are unacceptable to one or all
involved?
• How are alternatives weighed, ranked and
prioritized?
6. Act on the choice
▫ Taking action is the major goal of the process
▫ Participants must be empowered to make a difficult
decision, setting aside less acceptable alternatives
• Be empowered to make a difficult decision.
• Give yourself permission to set aside less
acceptable alternatives.
• Be attentive to the emotions involved in this
process.
7. Evaluate Outcomes of Action
▫ Participants begin a process of response and
evaluation
▫ Reflective sheds light on the effectiveness and
validity of the process
• Has the ethical dilemma been resolved?
• Have other dilemmas emerged related to the
action?
• How has the process affected those involved?
• Are further actions required?
Applying The Decision Making Process

• A couple is pregnant with their 2nd child after

numerous unsuccessful attempts with artificial
insemination. During a routine ultrasound at 28
weeks gestation, the physician discovers that the
fetus is anencephalic. The life expectancy of a n
anencephalic baby is only a few days to weeks
after birth. The couple struggles with the choice
to terminate the pregnancy at this time or to
carry the child to term