Ethical Decision Making

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Ethical Decision Making
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Morality and Moral Values

• Personal morality
• Societal morality
• Group morality

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Decisions and Actions Rules and Codes Moral
Principles Ethical Theories Moral Philosophy
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Moral Philosophy

• Teleological the end justifies the means
• Deontological the means need to be carefully
  weighed without primary concern for the outcome

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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

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Ethical Principles

• Nonmaleficence
• Beneficence
• Autonomy
• Justice
• Distributive
• Compensatory (and retributive)
• Procedural

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Rules and Codes

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

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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. 20018(5)459-468.
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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. 200010(3)239-260.
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Contrasting Norms, Cultural Beliefs and Values

• Self-reliance and individualism lead to valuing
  individual autonomy
• Informed consent advanced directives
• Porous social groups

• The individual as part of the larger whole values
  group cohesion
• 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.
19996(2)118-125.
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The Realm-Individual Process-Situation (RIPS)
Model of Ethical Decision Making

• A formalized approach to reflection and analysis
  of morality

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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

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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
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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

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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

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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
  decision-maker in some way
• Silence key parties realize ethical values are
  being challenged, but do nothing
• Distress
• Dilemma

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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

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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)

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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?

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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?

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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. 2002176175-176.
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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)

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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?