see attached ….
Week 4ish
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thanks
Article
An integrated ethical
decision-making model
for nurses
Eun-Jun Park
Kyungwon University, Korea
Abstract
The study reviewed 20 currently-available structured ethical decision-making models and developed an
integrated model consisting of six steps with useful questions and tools that help better performance
each step: (1) the identification of an ethical problem; (2) the collection of additional information to
identify the problem and develop solutions; (3) the development of alternatives for analysis and com-
parison; (4) the selection of the best alternatives and justification; (5) the development of diverse, prac-
tical ways to implement ethical decisions and actions; and (6) the evaluation of effects and development
of strategies to prevent a similar occurrence. From a pilot-test of the model, nursing students reported
positive experiences, including being satisfied with having access to a comprehensive review process of
the ethical aspects of decision making and becoming more confident in their decisions. There is a need
for the model to be further tested and refined in both the educational and practical environments.
Keywords
decision making, ethics, ethical issues, nursing ethics, problem solving
Introduction
Patients’ safety and well-being are dependent, to a large extent, on professionals’ ethical decisions.1
Regardless of his or her excellence in clinical knowledge and skills, a healthcare professional who has low
or non-existent ethical standards should be considered unfit to practice. For responsible healthcare, profes-
sionals have to be competent in ethical decision making.2 An ethical problem is ‘as [an ethical] matter or
issue that is difficult to deal with, solve, or overcome and which stands in need of a solution’ (p.94).3 Ethical
problems in a clinical setting are those we rarely confront in our daily lives, and ethical norms learned from
our parents or schools are not sufficient to resolve clinical ethical issues. There are concerns about profes-
sionals’ ethical competency. Health professionals often adopt an inconsistent decision-making process or
reach inconsistent ethical conclusions in attempts to resolve identical ethical problems.1,4,5 Moreover, they
tend to come to decisions of an ethical nature before reviewing all possible alternatives or going through a
systematic and comprehensive decision process.2 It is challenging for clinicians to make ethical decisions.
Health professionals attempt to achieve the best possible and morally-justifiable resolution while prior-
itizing a patient’s interest.6 Accordingly, the quality of ethical decision making should be evaluated in terms
not only of its conclusion but also the process of decision making. For example, whether all individuals
Corresponding author: Eun-Jun Park, Department of Nursing, Kyungwon University, San65, Bokjeong-Dong, Sujeong-Gu,
Seongnam-Si, Gyeonggi-Do, 461-701, Korea
Email: eunjunp@gmail.com
Nursing Ethics
19(1) 139–159
ª The Author(s) 2012
Reprints and permission:
sagepub.co.uk/journalsPermissions.nav
10.1177/0969733011413491
nej.sagepub.com
139
affected by the decision have an opportunity to share their informed decisions or preferences.7 An explicit
and systematic method for ethical decision making is highly likely to improve the quality of such deci-
sions for several reasons.2,8-11 First, ‘a model functions as an intellectual device that simplifies and clari-
fies the sources of moral perplexity and enables one to arrive at a self-directed choice’ (p.1701).2
Second, it eliminates a possibility of deviated assessment of an ethical problem, for example, not con-
sidering all relevant parties and their diverse preferences,12 or reaching conclusions based on his/her
intuition rather than on intellectual rigor.13,14 Third, ‘communication and documentation of an explana-
tion for a course of action’8 and collaboration among stakeholders become easier throughout an ethical
decision-making process when a systematic decision-making model is shared.7 A systematic decision-
making model helps identify where a gap in understanding an issue or a difference in value systems (dis-
agreements) exist among stakeholders (interdisciplinary team) through transparent communication.1,15,16
Finally, the use of a systematic model of ethical decision making will allow for the accumulation of
information concerning ethical decisions, thus revealing norms.7 Although nurses make ethical decisions
every day, we know little about how similar are our ethical decisions to those of other nurses. If we
collect information on our ethical decisions, codes of ethics can be developed being based on our nor-
mative ethics,7 which can be more acceptable and evidence based.
Structured models for ethical decision making have been introduced by different authors. To name a
few, Johnstone’s moral decision-making model3 includes stages to assess the situation, to identify moral
problem(s), to set moral goals and plan moral action, to implement moral plans of action, and to evaluate
moral outcomes. According to Davis, Fowler, and Aroskar,17 if a conflict of moral duties or values
exists, we need to go through the following stages: 1) review of the overall situation to identify what
is going on; 2) identification of the significant facts about the patient; 3) identification of the parties
or stakeholders involved in the situation or affected by the decision(s) that is made; 4) identification
of morally relevant legal data; 5) identification of specific conflicts of ethical principles or values; 6)
identification of possible choices, their intent, and probable consequences for the welfare of the patient(s)
as the primary concern; 7) identification of practical constraints and facilitators; 8) make recommenda-
tions for action; 9) take action if you are the decision maker and implementor of the decision(s) made;
and 10) review and evaluate the situation after action is taken. In addition, Thompson et al.’s11 DECIDE
model suggests to: 1) Define problems – what is an ethical issue?; 2) Ethical review – what principles
are relevant to case?; 3) Consider options; 4) Investigate – ethical outcomes, costs and benefits; 5)
Decide on action; and 6) Evaluate results. However, it is hard to say what are their strengths or weak-
nesses and which one is more greatly-accepted by clinicians. Therefore, the current study critically
reviewed structured ethical decision-making models found via a systematic search of literature and sug-
gested an integrated and comprehensive ethical decision-making model by synthesizing strengths of the
different ethical decision-making models and by pilot-testing it. The suggested ethical decision-making
model is meant to be prescriptive so that nurses may directly apply it in practice.
Methods
Peer-reviewed journal articles were searched using Medline and CINAHL databases. The following
keywords and the subject headings were entered into the PubMed and CINHAL interface on 30 June
2010: (ethical OR moral) AND ((decision AND making) OR (decision AND model)). Four hundred
and twenty-six articles from Medline and 202 additional articles from CINAHL were retrieved. Their
titles and abstracts were reviewed for potential relevance, and then the selected 78 articles were
reviewed for their full-text. Studies were selected if (1) their authors originally developed an original
ethical decision-making process or model, (2) the ethical decision-making process or model clearly
presented steps for decision, and (3) they were written in English. Studies were excluded mostly
140 Nursing Ethics 19(1)
140
because (1) the authors introduced or applied an ethical decision-making process or model developed
by other people, (2) they described only a theoretical background of ethical decision making without a
decision-making process, or (3) their ethical decision-making process or model were developed for
non-healthcare practitioners or for non-clinical settings, such as business, information technology,
education, or research. A report of an ethical decision-making process for family physicians of
Canada18 was included after reviewing references of the selected articles. Twenty structured ethical
decision-making processes were reviewed systematically.
An integrated ethical decision-making model was developed and modified through a pilot test of its
usability. In two nursing ethics courses, 67 second-year baccalaureate nursing students were asked to
solve four cases of clinical ethical problems through a group discussion involving three or four people
and to submit a report of their decisions. This was a regular classroom activity of a nursing ethics course
taught by the author. To test the developed model, 22 student groups discussed an initial two cases
before learning the model, and, after a brief orientation, a further two cases applying the model. After
the discussion class, the students were invited to participate in this study as a group by submitting their
reflective essay of how the use of the structured model influenced their decision-making process or out-
comes. Twenty student groups voluntarily participated without revealing their names, and thus individual
participants were not identifiable so as to protect the students. Accordingly, whether or not they parti-
cipated in this study, their grades or student-teacher relationships were unaffected.
Findings
Reviews of ethical decision-making or problem-solving models
Twenty different ethical decision-making models were classified into two groups and ordered by their
publication year: ‘Nine ethical decision-making processes’ (Table 1) and ‘Eleven ethical problem-
solving processes’ (Table 2). An ethical problem-solving process includes an ethical decision-
making process, which refers mainly to a cognitive process, but goes further by adding implementing
the decision and evaluating its results. However, the authors of the reviewed articles did not clearly
distinguish this difference, and interchangeably used the two terms: ‘ethical problem solving’ and
‘ethical decision making’. Only two studies1,18 out of the 11 (Table 2) explicitly acknowledged the
difference by mentioning it in their article titles. These two terms were differentiated in this study,
as necessary; otherwise the term ‘ethical decision making’ is used to refer to both, and they are ana-
lyzed and discussed together. The reviewed 20 studies were published from 1976 to 2010: one in the
1970s, seven in the 1980s, four in the 1990s, and eight in the 2000s. They show that interest in ethical
decision-making process has been ongoing and that new models are being constantly developed even
today. A chronological pattern of change was not found in ethical decision-making or problem-
solving models. Among the reviewed 20 models, seven were developed for RNs or nurse practi-
tioners, five for health professionals in general, four for physicians, two for psychologists, one for
social workers, and one for a neonatal intensive care unit.
Theoretical backgrounds and contextual factors. Most authors suggested ethical pluralism applying diverse
ethical theories and perspectives in decision making as one ethical theory or perspective was unlikely
to be a panacea for every ethical problem. Ethical pluralism seems to be natural in modern societies that
are experiencing an increasing diversity of values.3 By adopting various theoretical alternatives, nurses
are more likely to have a comprehensive moral vision.16 Deontology (principle-based approach) and
consequentialist theory (teleology, ends-based approach) were predominantly adopted by the authors
of the models, whereas some models were based on a single ethical theory: consequentialism.7,15,19
Park 141
141
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142
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In
d
iv
id
u
al
va
lu
e
sy
st
em
&
th
e
co
re
va
lu
es
o
f
th
e
u
n
it
7
st
ag
es
7
st
ag
es
6
st
ag
es
7
st
ag
es
1
.
St
at
e
th
e
p
ro
b
le
m
p
la
in
ly
(c
on
tin
ue
d)
143
T
a
b
le
1
(c
o
n
ti
n
u
e
d
)
D
eW
o
lf
B
o
se
k
(1
9
9
5
)1
5
M
at
ti
so
n
(2
0
0
0
)1
3
K
al
d
jia
n
et
al
.
(2
0
0
5
)9
B
au
m
an
n
-H
o
lz
le
et
al
.
(2
0
0
5
)1
4
1
.
Id
en
ti
fy
d
es
ir
ed
o
u
tc
o
m
es
2
.
A
ss
ig
n
u
ti
lit
ie
s
1
.B
ac
kg
ro
u
n
d
in
fo
rm
at
io
n
/c
as
e
d
et
ai
ls
2
.S
ep
ar
at
in
g
p
ra
ct
ic
e
co
n
si
d
er
at
io
n
s
an
d
et
h
ic
al
co
m
p
o
u
n
d
s
2
.
G
at
h
er
an
d
o
rg
an
iz
e
d
at
a:
m
ed
ic
al
fa
ct
s,
m
ed
ic
al
go
al
s,
p
at
ie
n
t’
s
go
al
s
an
d
p
re
fe
re
n
ce
s,
co
n
te
x
t
1
.
D
es
cr
ip
ti
o
n
o
f
th
e
ch
ild
’s
m
ed
ic
al
in
fo
rm
at
io
n
,
ca
re
an
d
so
ci
al
si
tu
at
io
n
2
.
D
iff
er
en
t
as
p
ec
ts
o
f
ev
al
u
at
io
n
th
e
in
fa
n
t’
s
ch
an
ce
s
o
f
su
rv
iv
al
th
e
in
fa
n
t’
s
ch
an
ce
s
o
f
d
yi
n
g
if
m
ec
h
an
ic
al
ve
n
ti
la
ti
o
n
an
d
o
th
er
cr
it
ic
al
as
si
st
an
ce
ar
e
co
n
ti
n
u
ed
/w
it
h
d
ra
w
n
th
e
in
fa
n
t’
s
ac
tu
al
su
ff
er
in
g
th
e
in
fa
n
t’
s
p
o
ss
ib
ili
ty
to
liv
e
in
d
ep
en
d
en
tl
y
in
th
e
fu
tu
re
w
it
h
o
u
t
d
ev
el
o
p
in
g
se
ve
re
h
an
d
ic
ap
s
3
.I
d
en
ti
fy
in
g
va
lu
e
te
n
si
o
n
s
4
.I
d
en
ti
fy
in
g
p
ri
n
ci
p
le
s
in
th
e
co
d
e
o
fe
th
ic
s
w
h
ic
h
b
ea
r
o
n
th
e
ca
se
3
.
A
sk
:
Is
th
e
p
ro
b
le
m
et
h
ic
al
?
4
.
A
sk
:
Is
m
o
re
in
fo
rm
at
io
n
o
r
d
ia
lo
gu
e
n
ee
d
ed
?
3
.
Id
en
ti
fy
p
o
ss
ib
le
ac
ti
o
n
s
4
.
A
ss
ig
n
p
ro
b
ab
ili
ti
es
5
.
C
al
cu
la
te
ex
p
ec
te
d
va
lu
es
5
.I
d
en
ti
fy
p
o
ss
ib
le
co
u
rs
es
o
f
ac
ti
o
n
(b
en
ef
it
/c
o
st
,
p
ro
je
ct
ed
o
u
tc
o
m
es
)
3
.
D
ev
el
o
p
in
g
at
le
as
t
th
re
e
d
iff
er
en
t
sc
en
ar
io
s
4
.
D
ec
is
io
n
(c
o
n
se
n
su
s)
5
.P
la
n
n
in
g
th
e
d
is
cu
ss
io
n
w
it
h
th
e
p
ar
en
ts
6
.
D
is
cu
ss
io
n
w
it
h
th
e
p
ar
en
ts
6
.
Id
en
ti
fy
th
e
b
es
t
ac
ti
o
n
6
.A
ss
es
si
n
g
w
h
ic
h
p
ri
o
ri
ty
/o
b
lig
a-
ti
o
n
to
m
ee
t
fo
re
m
o
st
an
d
ju
s-
ti
fy
in
g
th
e
ch
o
ic
e
o
f
ac
ti
o
n
7
.R
es
o
lu
ti
o
n
5
.
D
et
er
m
in
e
th
e
b
es
t
co
u
rs
e
o
f
ac
ti
o
n
an
d
su
p
p
o
rt
it
w
it
h
re
fe
re
n
ce
to
o
n
e
fo
r
m
o
re
so
u
rc
es
o
f
et
h
ic
al
va
lu
e:
et
h
ic
al
p
ri
n
ci
p
le
s,
ri
gh
ts
,
co
n
se
–
q
u
en
ce
s,
co
m
p
ar
ab
le
ca
se
s,
p
ro
fe
ss
io
n
al
gu
id
el
in
es
,
co
n
sc
ie
n
ti
o
u
s
p
ra
ct
ic
e
7
.
E
va
lu
at
e
th
e
ac
ti
o
n
ch
o
ic
e
(j
u
st
ifi
ca
ti
o
n
)
6
.
C
o
n
fir
m
th
e
ad
eq
u
ac
y
o
f
th
e
co
n
cl
u
si
o
n
7
.
E
va
lu
at
io
n
o
f
th
e
d
ec
is
io
n
m
ak
in
g
p
ro
ce
ss
144
T
a
b
le
2
.
E
le
ve
n
st
u
d
ie
s
o
f
et
h
ic
al
p
ro
b
le
m
so
lv
in
g
p
ro
ce
ss
es
M
u
rp
h
y
an
d
M
u
rp
h
y
(1
9
7
6
)1
9
A
ro
sk
ar
(1
9
8
6
)2
5
T
ym
ch
u
k
(1
9
8
6
)7
C
as
se
lls
an
d
R
ed
m
an
(1
9
8
9
)2
6
C
lin
ic
ia
n
s
in
ge
n
er
al
(T
h
e
U
n
iv
er
si
ty
o
f
C
o
lo
ra
d
o
M
ed
ic
al
C
en
te
r)
C
o
n
se
q
u
en
ti
al
is
m
R
N
s
C
o
n
se
q
u
en
ti
al
is
m
&
d
eo
n
to
lo
gy
P
sy
ch
o
lo
gi
st
s
C
o
n
se
q
u
en
ti
al
is
m
R
N
s
&
n
u
rs
in
g
st
u
d
en
ts
C
o
d
e
o
f
et
h
ic
s,
et
h
ic
al
p
ri
n
ci
p
le
s
9
st
ag
es
7
st
ag
es
7
st
ag
es
1
1
st
ag
es
1
.
Id
en
ti
fy
th
e
h
ea
lt
h
p
ro
b
le
m
.
2
.
Id
en
ti
fy
th
e
et
h
ic
al
p
ro
b
le
m
.
1
.D
is
ti
n
gu
is
h
in
g
a
p
re
d
o
m
in
an
tl
y
et
h
ic
al
si
tu
at
io
n
fr
o
m
o
n
e,
fo
r
ex
am
p
le
,
th
at
is
p
ri
m
ar
ily
a
co
m
m
u
n
ic
at
io
n
is
su
e
1
.I
d
en
ti
fy
th
e
m
o
ra
la
sp
ec
ts
o
fn
u
rs
in
g
ca
re
3
.
St
at
e
w
h
o
’s
in
vo
lv
ed
in
m
ak
in
g
th
e
d
ec
is
io
n
4
.I
d
en
ti
fy
yo
u
r
ro
le
(q
u
it
e
p
o
ss
ib
ly
,y
o
u
r
ro
le
m
ay
n
o
t
re
q
u
ir
e
a
d
ec
is
io
n
at
al
l.)
2
.
G
at
h
er
in
g
an
ad
eq
u
at
e
in
fo
rm
at
io
n
b
as
e
3
.
Id
en
ti
fy
in
g
th
e
va
lu
e
co
n
fli
ct
s
1
.
D
et
er
m
in
at
io
n
o
f
w
h
o
sh
o
u
ld
p
ar
ti
ci
p
at
e
in
th
e
d
ec
is
io
n
2
.
G
at
h
er
re
le
va
n
t
fa
ct
s
re
la
te
d
to
a
m
o
ra
l
is
su
e
3
.
C
la
ri
fy
an
d
ap
p
ly
p
er
so
n
al
va
lu
es
4
.
U
n
d
er
st
an
d
et
h
ic
al
th
eo
ri
es
an
d
p
ri
n
ci
p
le
s
5
.
U
ti
liz
e
co
m
p
et
en
t
in
te
rd
is
ci
p
lin
ar
y
re
so
u
rc
es
5
.C
o
n
si
d
er
as
m
an
y
p
o
ss
ib
le
al
te
rn
at
iv
e
d
ec
is
io
n
s
as
yo
u
ca
n
6
.
C
o
n
si
d
er
th
e
lo
n
ga
n
d
sh
o
rt
-r
an
ge
co
n
se
q
u
en
ce
s
o
f
ea
ch
al
te
rn
at
iv
e
d
ec
is
io
n
4
.
Se
ei
n
g
w
h
at
h
el
p
m
ay
b
e
ga
in
ed
b
y
lo
o
ki
n
g
at
th
e
al
te
rn
at
iv
es
fr
o
m
th
e
p
er
sp
ec
ti
ve
o
f
et
h
ic
al
th
eo
ri
es
an
d
co
n
ce
p
ts
2
.
D
et
er
m
in
at
io
n
o
f
av
ai
la
b
le
al
te
rn
at
iv
es
3
.
D
et
er
m
in
at
io
n
o
f
w
h
o
sh
o
u
ld
d
ec
id
e
w
h
ic
h
al
te
rn
at
iv
e
to
im
p
le
m
en
t
6
.
P
ro
p
o
se
al
te
rn
at
iv
e
ac
ti
o
n
s
7
.
A
p
p
ly
n
u
rs
in
g
co
d
e(
s)
o
f
et
h
ic
s
to
h
el
p
gu
id
e
ac
ti
o
n
s
7
.
R
ea
ch
yo
u
r
d
ec
is
io
n
8
.C
o
n
si
d
er
h
o
w
th
is
d
ec
is
io
n
fit
s
in
w
it
h
yo
u
r
ge
n
er
al
p
h
ilo
so
p
h
y
o
f
p
at
ie
n
t
ca
re
5
.
M
ak
in
g
a
d
ec
is
io
n
4
.D
et
er
m
in
at
io
n
o
fw
h
ic
h
al
te
rn
at
iv
e
to
im
p
le
m
en
t
5
.
R
ev
ie
w
p
ro
ce
d
u
re
s
8
.
C
h
o
o
se
an
d
ac
t
o
n
a
re
so
lu
ti
ve
ac
ti
o
n
6
.
T
ak
in
g
ac
ti
o
n
6
.
Im
p
le
m
en
ta
ti
o
n
9
.
P
ar
ti
ci
p
at
e
ac
ti
ve
ly
in
re
so
lv
in
g
th
e
is
su
e
1
0
.
A
p
p
ly
st
at
e/
fe
d
er
al
la
w
s
go
ve
rn
in
g
n
u
rs
in
g
p
ra
ct
ic
e
9
.F
o
llo
w
th
e
si
tu
at
io
n
u
n
ti
l
yo
u
ca
n
se
e
th
e
ac
tu
al
re
su
lt
s
o
fy
o
u
r
d
ec
is
io
n
,a
n
d
u
se
th
is
in
fo
rm
at
io
n
to
h
el
p
m
ak
in
g
fu
tu
re
d
ec
is
io
n
s
7
.
R
ev
ie
w
in
g
th
e
p
ro
ce
ss
to
le
ar
n
w
h
at
n
ee
d
s
to
b
e
ch
an
ge
d
in
d
ea
lin
g
w
it
h
fu
tu
re
et
h
ic
al
si
tu
at
io
n
s
in
p
at
ie
n
t
ca
re
7
.
E
va
lu
at
io
n
1
1
.
E
va
lu
at
e
th
e
re
so
lu
ti
ve
ac
ti
o
n
ta
ke
n
(c
on
tin
ue
d)
145
T
a
b
le
2
(c
o
n
ti
n
u
e
d
)
D
eW
o
lf
(1
9
8
9
)3
0
T
h
o
m
p
so
n
an
d
T
h
o
m
p
so
n
(1
9
9
0
)1
2
H
ad
jis
ta
vr
o
p
o
u
lo
s
an
d
M
al
lo
y
(2
0
0
0
)2
2
R
N
s
A
n
te
ce
d
en
t
fa
ct
o
rs
:
p
ro
x
im
it
y
in
ti
m
e,
an
em
o
ti
o
n
al
in
vo
lv
em
en
t,
a
fa
ct
u
al
d
ef
ic
it
,
p
er
so
n
al
in
vo
lv
em
en
t,
co
n
fu
–
si
o
n
o
f
va
lu
es
Su
p
p
o
rt
in
g/
n
eg
at
in
g
fa
ct
o
rs
to
su
p
p
o
rt
a
p
re
fe
rr
ed
o
p
ti
o
n
in
st
ag
e
3
:
as
su
m
p
–
ti
o
n
s,
co
n
se
q
u
en
ce
s,
le
ga
l
fa
ct
o
rs
,
em
o
ti
o
n
s,
p
ro
x
im
it
y
in
d
is
ta
n
ce
an
d
ti
m
e,
p
re
vi
o
u
s
ex
p
er
ie
n
ce
s,
va
lu
es
,
fa
ct
s,
an
d
ro
le
re
sp
o
n
si
b
ili
ti
es
M
ay
b
e
cl
in
ic
ia
n
s
in
ge
n
er
al
(n
o
t
m
en
ti
o
n
ed
)
U
ti
lit
ar
ia
n
is
m
,
d
eo
n
to
lo
gy
C
o
n
te
n
ts
an
d
d
et
ai
ls
ar
e
p
ro
vi
d
ed
in
ea
ch
st
ag
e
P
sy
ch
o
lo
gi
st
s
T
el
eo
lo
gy
,
d
eo
n
to
lo
gy
,
ex
is
te
n
ti
al
is
m
,
sy
n
th
es
is
o
f
d
iff
er
en
t
et
h
ic
al
th
eo
ri
es
In
d
iv
id
u
al
in
flu
en
ce
s:
le
ve
l
o
f
co
gn
it
iv
e
m
o
ra
l
d
ev
el
o
p
m
en
t,
et
h
ic
al
o
ri
en
ta
–
ti
o
n
,
d
em
o
gr
ap
h
ic
p
ro
fil
e
Is
su
e
sp
ec
ifi
c
in
flu
en
ce
s
(m
o
ra
l
in
te
n
–
si
ty
):
te
m
p
o
ra
l
im
m
ed
ia
cy
,
m
ag
n
it
u
d
e
o
f
co
n
se
q
u
en
ce
,
p
ro
x
im
it
y,
co
n
ce
n
–
tr
at
io
n
o
f
ef
fe
ct
,
p
ro
b
ab
ili
ty
o
f
ef
fe
ct
,
an
d
so
ci
al
co
n
se
n
su
s
Si
gn
ifi
ca
n
t
o
th
er
in
flu
en
ce
s
(f
am
ily
,
fr
ie
n
d
s,
co
w
o
rk
er
s,
p
ee
rs
,
an
d
/o
r
a
w
id
e
va
ri
et
y
o
f
ex
tr
an
eo
u
s
st
ak
eh
o
ld
er
s)
Si
tu
at
io
n
al
in
flu
en
ce
s:
cu
lt
u
re
/c
lim
at
e
an
d
p
h
ys
ic
al
st
ru
ct
u
re
s
o
f
o
rg
an
iz
at
io
n
s
E
x
te
rn
al
in
flu
en
ce
s:
so
ci
et
y,
p
o
lit
ic
s,
ec
o
n
o
m
ic
s,
an
d
te
ch
n
o
lo
gy
6
st
ag
es
1
0
st
ag
es
7
st
ag
es
1
.P
er
ce
iv
e
th
e
si
tu
at
io
n
as
h
av
in
g
et
h
ic
al
co
n
ce
rn
s
1
.
R
ev
ie
w
th
e
si
tu
at
io
n
an
d
id
en
ti
fy
a)
h
ea
lt
h
p
ro
b
le
m
s,
b
)
d
ec
is
io
n
(s
)
n
ee
d
ed
,
an
d
c)
ke
y
in
d
iv
id
u
al
s
in
vo
lv
ed
1
.
Id
en
ti
fic
at
io
n
o
f
et
h
ic
al
ly
re
le
va
n
t
is
su
es
an
d
p
ra
ct
ic
es
(c
on
tin
ue
d)
146
T
a
b
le
2
(c
o
n
ti
n
u
e
d
)
D
eW
o
lf
(1
9
8
9
)3
0
T
h
o
m
p
so
n
an
d
T
h
o
m
p
so
n
(1
9
9
0
)1
2
H
ad
jis
ta
vr
o
p
o
u
lo
s
an
d
M
al
lo
y
(2
0
0
0
)2
2
2
.
G
at
he
r
in
fo
rm
at
io
n
th
at
is
av
ai
la
bl
e
in
o
rd
er
to
a)
cl
ar
ify
th
e
si
tu
at
io
n,
b)
un
de
rs
ta
nd
th
e
le
ga
li
m
pl
ic
at
io
ns
,c
)
id
en
ti
fy
th
e
bu
re
au
cr
at
ic
o
r
lo
ya
lt
y
is
su
es
3
.I
d
en
ti
fy
th
e
et
h
ic
al
is
su
es
o
r
co
n
ce
rn
s
in
th
e
si
tu
at
io
n
an
d
a)
ex
p
lo
re
th
e
h
is
to
ri
ca
l
ro
o
ts
,
b
)
ex
p
lo
re
cu
rr
en
t
p
h
ilo
so
p
h
ic
al
/r
el
ig
io
u
s
p
o
si
ti
o
n
s
o
n
ea
ch
,
an
d
c)
id
en
ti
fy
cu
rr
en
t
so
ci
et
al
vi
ew
s
o
n
ea
ch
4
.
E
x
am
in
e
p
er
so
n
al
an
d
p
ro
fe
ss
io
n
al
va
lu
es
r/
t
ea
ch
is
su
e
5
.
Id
en
ti
fy
th
e
m
o
ra
l
p
o
si
ti
o
n
o
f
ke
y
in
d
iv
id
u
al
s
6
.
Id
en
ti
fy
va
lu
e
co
n
fli
ct
s,
if
an
y
7
.D
et
er
m
in
e
w
h
o
sh
o
u
ld
m
ak
e
th
e
fin
al
d
ec
is
io
n
8
.
Id
en
ti
fy
th
e
ra
n
ge
o
f
p
o
ss
ib
le
ac
ti
o
n
s
an
d
a)
d
es
cr
ib
e
th
e
an
ti
ci
p
at
ed
o
u
t-
co
m
e
fo
r
ea
ch
ac
ti
o
n
,
b
)
id
en
ti
fy
th
e
el
em
en
ts
o
f
m
o
ra
l
ju
st
ifi
ca
ti
o
n
fo
r
ea
ch
ac
ti
o
n
,c
)
n
o
te
if
th
e
h
ie
ra
rc
h
y
o
f
p
ri
n
ci
p
le
s
o
r
u
ti
lit
ar
ia
n
is
m
is
to
b
e
u
se
d
2
.D
ev
el
o
p
m
en
t
o
fa
lt
er
n
at
iv
e
co
u
rs
es
o
f
ac
ti
o
n
3
.
A
n
al
ys
is
o
f
th
e
lik
el
y
sh
o
rt
-t
er
m
,
o
n
go
in
g
an
d
lo
n
g-
te
rm
ri
sk
s
an
d
b
en
ef
it
s
o
f
ea
ch
co
u
rs
e
o
f
ac
ti
o
n
o
n
th
e
in
d
iv
id
u
al
(s
)/
gr
o
u
p
(s
)
in
vo
lv
ed
o
r
lik
el
y
to
b
e
af
fe
ct
ed
2
.
C
h
o
o
se
a
p
re
fe
rr
ed
o
p
ti
o
n
3
.
U
se
va
ri
o
u
s
fa
ct
o
r
to
su
p
p
o
rt
th
ei
r
p
re
fe
rr
ed
o
p
ti
o
n
4
.
C
o
m
m
u
n
ic
at
e
th
ei
r
o
p
ti
o
n
ch
o
ic
e
9
.D
ec
id
e
o
n
a
co
u
rs
e
o
fa
ct
io
n
an
d
ca
rr
y
it
o
u
t
4
.
C
h
o
ic
e
o
f
co
u
rs
e
o
f
ac
ti
o
n
af
te
r
co
n
sc
ie
n
ti
o
u
s
ap
p
lic
at
io
n
o
f
ex
is
ti
n
g
p
ri
n
ci
p
le
s,
va
lu
es
,
an
d
st
an
d
ar
d
s
5
.
Im
p
le
m
en
t
an
o
p
ti
o
n
5
.A
ct
io
n
w
it
h
a
co
m
m
it
m
en
t
to
as
su
m
e
re
sp
o
n
si
b
ili
ty
fo
r
th
e
co
n
se
q
u
en
ce
s
o
f
th
e
ac
ti
o
n
6
.
E
va
lu
at
e
th
e
d
ec
is
io
n
-m
ak
in
g
p
ro
ce
ss
an
d
th
ei
r
ac
ti
o
n
s
1
0
.
E
va
lu
at
e
th
e
re
su
lt
s
o
f
th
e
d
ec
is
io
n
/
ac
ti
o
n
an
d
n
o
te
a)
w
h
et
h
er
th
e
ex
p
ec
te
d
o
u
tc
o
m
es
o
cc
u
rr
ed
,
b
)
if
a
n
ew
d
ec
is
io
n
is
n
ee
d
ed
,
c)
if
th
e
d
ec
is
io
n
p
ro
ce
ss
is
co
m
p
le
te
,d
)
w
h
at
el
em
en
ts
o
f
th
is
p
ro
ce
ss
ca
n
b
e
u
se
d
in
si
m
ila
r
si
tu
at
io
n
s
6
.E
va
lu
at
io
n
o
ft
h
e
re
su
lt
s
o
ft
h
e
co
u
rs
e
o
f
ac
ti
o
n
7
.
A
ss
u
m
p
ti
o
n
o
f
re
sp
o
n
si
b
ili
ty
fo
r
co
n
se
q
u
en
ce
s
o
f
ac
ti
o
n
,
in
cl
u
d
in
g
co
rr
ec
ti
o
n
o
f
n
eg
at
iv
e
co
n
se
q
u
en
ce
s,
if
an
y,
o
r
re
-e
n
ga
gi
n
g
th
e
d
ec
is
io
n
–
m
ak
in
g
p
ro
ce
ss
if
th
e
et
h
ic
al
is
su
e
is
n
o
t
re
so
lv
ed
(c
on
tin
ue
d)
147
T
a
b
le
2
(c
o
n
ti
n
u
e
d
)
O
ge
rs
h
o
k
(2
0
0
2
)2
3
D
ev
lin
an
d
M
ag
ill
(2
0
0
6
)2
7
K
ir
sc
h
(2
0
0
9
)1
B
er
ez
a
(2
0
1
0
)1
8
R
N
s
A
n
es
th
es
io
lo
gi
st
s
U
ti
lit
ar
ia
n
is
m
,
d
eo
n
to
lo
gy
,
lib
er
al
in
d
iv
i-
d
u
al
is
m
,
co
m
m
u
n
it
ar
ia
n
is
m
,
et
h
ic
s
o
f
ca
re
,
et
c.
A
ll
h
ea
lt
h
ca
re
p
ro
vi
d
er
s
R
ea
lm
-I
n
d
iv
id
u
al
P
ro
ce
ss
-S
it
u
at
io
n
(R
IP
S)
m
o
d
el
R
u
le
-b
as
ed
ap
p
ro
ac
h
,
en
d
s-
b
as
ed
ap
p
ro
ac
h
,
&
ca
re
-b
as
ed
ap
p
ro
ac
h
Fa
m
ily
p
h
ys
ic
ia
n
s
o
f
C
an
ad
a
T
el
eo
lo
gy
,
d
eo
n
to
lo
gy
,
ca
ri
n
g
et
h
ic
,
co
m
m
u
n
it
ar
ia
n
is
m
,
vi
rt
u
e
et
h
ic
,
ca
su
is
tr
y
6
st
ag
es
4
st
ag
es
4
st
ag
es
6
st
ag
es
1
.
Id
en
ti
fy
th
e
ex
is
te
n
ce
o
f
an
et
h
ic
al
d
ile
m
m
a
o
r
si
tu
at
io
n
1
.
Id
en
ti
fie
s
th
e
p
ro
b
le
m
T
h
e
re
co
gn
it
io
n
o
f
th
e
p
ro
b
le
m
’s
re
le
va
n
t
as
p
ec
ts
T
h
e
d
es
ig
n
at
io
n
o
f
th
e
ro
o
t
p
ro
b
le
m
T
h
e
ev
al
u
at
io
n
o
f
th
e
ca
u
se
an
d
ef
fe
ct
re
la
ti
o
n
s
in
th
e
p
ro
b
le
m
1
.R
ec
o
gn
iz
e
an
d
d
ef
in
e
th
e
et
h
ic
al
is
su
es
R
ea
lm
:
in
d
iv
id
u
al
,
o
rg
an
iz
at
io
n
al
/
in
st
it
u
ti
o
n
al
,
so
ci
al
In
d
iv
id
u
al
p
ro
ce
ss
:
m
o
ra
l
se
n
si
ti
vi
ty
,
m
o
ra
l
ju
d
gm
en
t,
m
o
ra
l
m
o
ti
va
ti
o
n
,
m
o
ra
l
co
u
ra
ge
,
m
o
ra
l
fa
ilu
re
Si
tu
at
io
n
:
is
su
e
o
r
p
ro
b
le
m
,
d
ile
m
m
a,
d
is
tr
es
s,
te
m
p
ta
ti
o
n
,
si
le
n
ce
1
.
Id
en
ti
fy
an
d
ar
ti
cu
la
te
th
e
et
h
ic
al
q
u
es
ti
o
n
(s
)
o
r
d
ile
m
m
a(
s)
to
b
e
ad
d
re
ss
ed
2
.
G
at
h
er
an
d
an
al
yz
e
re
le
va
n
t
in
fo
rm
at
io
n
3
.
C
la
ri
fy
p
er
so
n
al
va
lu
es
an
d
m
o
ra
l
p
o
si
ti
o
n
2
.
R
ef
le
ct
W
h
at
el
se
d
o
w
e
n
ee
d
to
kn
o
w
ab
o
u
t
th
e
si
tu
at
io
n
,
th
e
p
at
ie
n
t,
an
d
th
e
fa
m
ily
2
.
G
at
h
er
al
l
n
ec
es
sa
ry
an
d
re
le
va
n
t
in
fo
rm
at
io
n
:
b
io
lo
gi
ca
l,
p
sy
ch
o
lo
gi
–
ca
l,
an
d
so
ci
al
4
.
B
as
ed
o
n
st
ag
e
2
&
3
d
et
er
m
in
e
o
p
ti
o
n
s
2
.
T
h
re
e
st
ag
es
to
re
so
lv
e
th
e
d
ile
m
m
a
2
.1
.T
h
e
cl
ar
ifi
ca
ti
o
n
o
r
ev
al
u
at
io
n
o
ft
h
e
fe
as
ib
le
o
p
ti
o
n
s
W
h
at
ar
e
th
e
co
n
se
q
u
en
ce
s
o
f
ac
ti
o
n
?
W
h
at
ar
e
th
e
co
n
se
q
u
en
ce
s
o
f
in
ac
ti
o
n
?
T
h
e
ad
ap
te
d
K
id
d
er
te
st
fo
r
ri
gh
t
ve
rs
u
s
w
ro
n
g?
:
Is
it
ill
eg
al
?,
th
e
st
en
ch
te
st
,
th
e
fr
o
n
t
p
ag
e
te
st
,t
h
e
m
o
m
te
st
,a
n
d
th
e
p
ro
fe
ss
io
n
al
va
lu
es
te
st
3
.
A
n
al
yz
e
th
e
in
fo
rm
at
io
n
in
co
n
te
x
t
o
f
th
e
q
u
es
ti
o
n
(s
)
3
.1
.
G
en
er
at
e
al
l
re
al
o
p
ti
o
n
s
3
.2
.
C
o
n
si
d
er
ea
ch
o
p
ti
o
n
in
te
rm
s
o
f
th
e
re
le
va
n
t
va
lu
es
,
p
ri
n
ci
p
le
s
an
d
co
n
se
q
u
en
ce
s:
5
.
M
ak
e
a
re
sp
o
n
si
b
le
co
lla
b
o
ra
ti
ve
d
ec
is
io
n
an
d
ta
ke
ac
ti
o
n
2
.2
.
T
h
e
d
et
er
m
in
at
io
n
o
f
th
e
b
es
t
so
lu
ti
o
n
to
th
e
p
ro
b
le
m
3
.
D
ec
id
e
th
e
ri
gh
t
th
in
g
to
d
o
3
.3
.
A
rt
ic
u
la
te
yo
u
r
ch
o
ic
e
b
y
fr
am
in
g
it
as
an
et
h
ic
al
ar
gu
m
en
t
3
.4
.
C
h
ec
k
fo
r
co
n
si
st
en
cy
:
is
th
e
co
n
cl
u
si
o
n
co
n
si
st
en
t
w
it
h
fu
n
d
a-
m
en
ta
lly
ac
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Caring ethics (care-based approach) and virtue ethics1,18 were rather uncommon in the reviewed models.
Virtues are the elements of desirable moral character, and caring is an essential virtue, especially for
nurses.16,20 Both virtue ethics and caring ethics support good ethical decision making of nurses. However,
they are regarded as being limited in the guidance of ethically correct actions in troubling situations, and
therefore they ‘cannot serve as the basis of a comprehensive ethical theory’ (p.43).16 In addition, although
caring ethics is readily accepted in the nursing profession, it is not commonly found in other health profes-
sions.16 It is this which may limit nurses’ collaboration with other professionals in solving ethical problems.
Moreover, in a systematic decision-making model using an analytical approach, virtue ethics and caring
ethics may be less preferable than deontological or teleological principles (the rational calculation of
utilities).20 In addition to ethical theory, the authors suggested diverse guides for ethical decision making,
including ethical principles (respect for patient autonomy, nonmaleficence, beneficence, and justice),
ethical rules (fidelity, veracity, and confidentiality), code of ethics, comparable cases in the past (casuistry),
and health professionals’ conscience.
At the same time, some authors stressed contextual factors like individual or organizational characteristics
that may influence ethical decision making.6,13,21,22 Health professionals’ individual characteristics that
must be taken into account include personal value systems, perspectives of the health professional-patient
relationship (paternalistic mode vs participatory mode vs advocate, for example), role responsibility,
decision-making styles, level of cognitive moral development, ethical orientation, and demographic profile.
Organizational characteristics influencing ethical decision making include organizational culture, policy, a
line of authority, and communication system. An ethical problem cannot be solved simply by following a
formula, and should be approached in consideration of its particular circumstances. The contextual factors
that directly or indirectly influence the quality of ethical decision making should be carefully examined.
Stages of the process of ethical decision making or problem solving. The authors of the reviewed models clearly
presented necessary steps for decision making or problem solving, but explanations about how to better per-
form each step or which aspects to be considered in the field of healthcare appeared insufficient. The num-
ber of stages of ethical decision-making or problem-solving processes varied from four to 11. The authors
suggested very analogous decision-making or problem-solving processes with a general consensus. As
shown in Table 1, an ethical decision-making process was grouped into five: 1) a pre-information collection
stage including a statement or perception of an ethical problem; 2) information collection; 3) a post-
information collection stage including mostly identification of an ethical problem; 4) identification and
analysis of alternative actions; and 5) selection of an alternative and justification of the decision. An ethical
problem-solving process had two more steps than an ethical decision-making process: implementation of a
chosen action, and evaluation of its results. In Tables 1 and 2, comparable similar stages are placed on the
same horizontal line for easy comparison. If two stages are combined into one, it is placed in the line of the
earlier stage, as seen in the last stage of ‘implement, evaluate, reassess’ of the ethical problem-solving pro-
cess by Kirsch (Table 2).
Stages of identification of an ethical problem and gathering information. A rather big difference in the reviewed
processes was found in the first three stages until identifying the ethical problem. Six models9,12,21,23-25 out
of 20 had all of the first three stages, which were from problem statement or any other actions before infor-
mation collection to information collection, and to an accurate identification of an ethical problem. Six
models1,18,19,26-28 had the first two stages, problem statement and information collection, and omitted the
third stage of confirmation of an ethical problem. In these models, information seemed to be collected for
developing alternatives rather than clarifying an ethical problem. Three models6,13,29 started the process
right away with information collection, which was followed by identification of an ethical problem.
Another three models7,14,15 started with the second stage of information collection and directly moved to
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149
the fourth stage of identification and analysis of alternative actions without mentioning a stage of statement
(stage 1) or identification of an ethical problem (stage 3). However, it seems to be invalid to find solutions
without knowing the exact problem. A stage for stating or identifying a specific ethical problem was critical
in order to learn what the problem was and whether the problem was an ethical issue or a non-ethical issue,
such as a communication problem, a patient-nurse relationship, or individual attitudes.
Gathering information is necessary for clarifying the problem and in some cases the ethical problem at
first needs to be restated or can even be concluded as non-ethical while searching primary causes or reasons
of the issue at stake. Information to be collected is not always stated in the models; it can be either facts or
values/preferences of involved individuals, either medical or non-medical aspects. The models often
required the identification of those individuals who should be involved in decision making and whose values
should be considered. Accordingly, information can be collected not only from a patient himself/herself but
also other stakeholders including family members, health professionals, institutions, payers, or communities.
The other two models22,30 started with either a first stage of problem statement or the third stage of iden-
tification of ethical problem and then directly moved to the fourth stage of identification and analysis of alter-
native actions. In the models that contained all of the first three stages,9,12,21,23-25 the first and the third stage
were different: an ethical problem was found and plainly stated at the first stage and clarified in the third as a
result of gathering further information. Not all authors believed that additional information was needed to
clearly identify an ethical problem. However, in most occasions a stage of information gathering seems to
be critical for clarifying the issue or for developing alternatives even if it was not mentioned in an ethical
decision-making or problem-solving model. The amount of information that needs to be additionally col-
lected to identify an ethical issue may vary, depending on how much information is already known to the
involved actors at the start point. It is tentatively concluded that an ethical decision-making process is not
necessarily linear or proceeds in a single direction: at any step of an ethical decision-making process, deci-
sion makers can go back to the step of information collection.
Stages of selecting an alternative and evaluation. Sixteen models out of 20 included the fourth stage of identi-
fication and analysis of all possible alternatives. Kirsh,1 though, approached ethical problem solving with a
do-or-undo perspective, limiting consideration of diverse alternatives. In four models,1,6,29,30 the fourth
stage of developing and analyzing possible alternatives was omitted and moved to a fifth stage of choosing
one ethically right action. These authors seemed to believe that we can determine one solution if we clearly
understand the situation including a patient’s preference or relevant ethical principles. Even if this is true, a
choice would be better justified when the alternatives are compared considering the same condition. Justi-
fication of the selected decision in the fifth stage is critical for an ethical decision-making process because a
decision that cannot be justified or is reached without knowing the reason is not considered ethical. Only
eight models6,9,13,15,18,19,21,30 clearly stated their justification of the selected alternative.
Most of the nine ethical decision-making models ended by choosing one solution or justifying it; however,
Haddad’s model24 added the last stage to decide ways to implement the choice, and the model of Baumann-
Holze et al.14 added a final stage in order to evaluate the decision-making process. All except one of the 11
ethical problem-solving models ended with an evaluation stage.27 The content of evaluation was not clearly
stated in most models, but some mentioned that both decision-making process and the results/effects of the
action need to be evaluated at the end.12,22,25,28,30 Unlike these models, Tymchuk7 suggested that the ethical
decision-making process be evaluated right after deciding the best solution and before implementing it,
which is similarly found in Baumann-Holze et al.14 In this way, the quality of ethical decision making or
problem solving is likely to be better satisfied.
Some ethical decision-making or problem-solving models mentioned directly or indirectly a feedback
loop; for example, by re-engaging the decision-making process or following up the case.1,12,18,19,22 Consen-
sus in ethical decision can be obtained through a collaborative decision-making process by communicating
150 Nursing Ethics 19(1)
150
moral positions or preferences of key individuals and by brainstorming possible alternatives together. Four
models14,26,28,30 mentioned shared decision making or collaboration for ethical problem solving.
Integrated ethical decision-making model
The strengths and weaknesses of the reviewed ethical decision-making models were critically evaluated and
taken into account in the integrated model of six steps, as presented in Appendix 1. This study tried not only
to logically integrate the reviewed processes but also to suggest considerations at each step. To be accurate,
this model is a problem-solving model, though here in the current study, it is called by the more conventional
title, a decision-making model. Appendix 1 summarizes this ethical decision-making model with its appli-
cation to a clinical case.
Step 1. State an ethical problem. Any ethical decision-making process starts with perceiving the problem. One
of the common mistakes among nurses is that they make statements concerning ethical issues using action-
oriented terms or those connected with a do-undo approach. Ethical problems should be stated in terms of
ethical values, and thus a decision process is more likely to be focused on ethical aspects rather than on
practical feasibility. It is critical to consider ethical principles and values separately from non-ethical and
practical aspects like environmental or personal constraints: if not, an ethical decision can be affected by
non-ethical and practical reasoning. Certain problems that initially appear to be ethical in nature may reveal
themselves to be communication difficulties, clinician-patient relationship issues, or legal problems. As an
example, when a nurse is requested to assist voluntary euthanasia of a patient suffering from irremediable
and intolerable pain, she/he refuses the request because she/he would be charged for murder even if she
believes voluntary euthanasia is ethically justified in this case.3 In this hypothetical case, the nurse’s deci-
sion is based on legality rather than on ethics.
Stakeholders’ different perceptions of the problem are likely to bring about different attitudes in an
approach to the problem. Evaluating some characteristics of the problem may help clarify one’s perception
and attitudes throughout the decision-making process, like questions of temporal urgency, the magnitude of
consequences, and whether the ethical problem already exists or is likely to occur.22 For instance, when
health professionals confront a problem requiring an immediate decision, they may not be able to wait for
a complete consensus among all key individuals, they may need to compromise someone’s values to save
a patient’s life, despite possibly deceiving a patient temporarily. In addition, the degree to which our ethical
behavior influences a patient’s life, and the level of seriousness of the ethical problem is likely to influence
attitudes and the level of expected efforts of involved parties. These questions can help clarify the problem
and reveal a gap of understanding among stakeholders. However, further information may be required to
clarify the problem, identify reasons behind it, or to suggest alternatives.
Step 2. Additional information collection and analysis of the problem. To decide the range of information, nurses
first need to know who are involved in this issue and what information is needed from each actor or party. In
Appendix 1, a cross table is a summary of what kind of information is necessary from whom. Stakeholders
can be roughly grouped into four: 1) patients; 2) family members as caregivers or surrogates; 3) health pro-
fessionals; and 4) environments including an institute, associations of health professionals, or a society with
culture, law, policy, or values common to that social group. The types of information required to overcome a
problem are grouped into four: 1) biological aspects; 2) psychological aspects; 3) social or historical
aspects; and 4) goals, preferences, or values related to the issue. As seen in Appendix 1, when the involved
actors and types of information are cross-referenced, the necessary information to collect can be more easily
identified. Because ethical problems occur when values or goals are inconsistent among stakeholders, this
information needs to be learned from all stakeholders regarding the specific ethical problem with which
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they are confronted. In addition, aspects such as biological, psychological, and social or historical related to
the current situation should be learned from different stakeholders. Certain types of information, like health
professionals’ biological aspects or an institute’s biological or psychological aspects, appeared not relevant
to the solution of most ethical problems. In this process, professionals may need to provide the actors with
information needed to establish their own perspectives or opinions regarding the problem. If a consensus
among stakeholders is luckily obtained in this step while important information is communicated, the actors
may be able to stop at that point and the problem is solved. After reviewing all relevant information, pro-
fessionals need to return to the statement of ethical problems in Step 1 and confirm the first statement or
restate it as accurate. If the problem is found to be a non-ethical issue, we need to apply a general
problem-solving process, as appropriate.
Step 3. Develop alternatives and analyze and compare them. Now all individuals affected by the decision are
sharing necessary information and the problem and the reasons for and backgrounds of value conflicts
should be clear. Accordingly, all possible alternatives/solutions are now suggested and shared among sta-
keholders. At this stage, all possibly right or wrong and good or bad actions should be included and
reviewed in terms of ethics rather than practical feasibility. Stakeholders have to analyze and compare the
alternatives based on diverse ethical theories and principles, codes of ethics, legal aspects, personal con-
science or religious beliefs, and an institute’s or a society’s values or policy. It is more reasonable to apply
diverse ethical theories or perspectives altogether to compare multiple alternatives. Unlike certain other
fields of human endeavor, such as business, wherein ethical decisions are more often decided by its conse-
quences, nurses cannot make an ethical decision based solely on consequence and always have to take seri-
ously a deontological perspective considering their duties as healthcare providers as well as patients’ rights.
Common ethical rules are fidelity, veracity, and confidentiality, while classical ethical principles are respect
for patient autonomy, nonmaleficence, beneficence, and justice in healthcare.31 The most common ethical
theories include utilitarianism or ends-based; deontology or duty-based; virtue ethics (is this decision con-
sistent with what the nurse as a human being values?); and caring ethics (would this be the type of care you
would want for yourself if you were the patient?).
Lewis et al.’s Options, Outcomes, Values and Likelihoods (OOVL) Guide,32 shown in the clinical case in
Appendix 1, is useful to find an alternative according to utilitarian/consequentialist theory. Alternatives are
listed at the left column and all possible long-term and short-term outcomes of different alternatives are listed
at the top horizontal row. Values of different outcomes are evaluated using a Likert type scale: different par-
ties may have different answers. In addition, for each alternative a nurse assesses the possibility of relevant
outcomes for each alternative. When this table is filled out, which alternative should be chosen becomes
more visible.
Step 4. Select the best alternative and justify your decision. In ethical decision making, the purpose is to find the
best solution with which most parties, including the patient, are satisfied. Through the process of analysis
and comparison, a nurse has to decide the best choice and justify it. Even though a certain behavior brings
about good or right results, it is not ethical behavior if you cannot justify it. Justification is essential and a
nurse has to be able to reasonably respond to differing opinions. There are some questions nurses can apply
to learn whether they are confident with their decision. For example, they can answer the five questions
suggested by Edgar33 – legal test, front-page test, gut-feeling test, role model test, professional standard test,
as presented in Appendix 1 – assuming a situation when the chosen alternative was implemented.
Step 5. Develop strategies to successfully implement the chosen alternative and take action. When nurses are con-
fident with what is ethically right or good, they have to plan how it can be actualized. They should not
restrain ethically correct decisions and have to find the best strategies to support their ethical decision.
152 Nursing Ethics 19(1)
152
At this point, all of the involved health professionals have to actively participate in developing the best way
to implement the ethical decision regardless of whether the final decision is the one he or she originally
intended.
Step 6. Evaluation. Healthcare professionals need to evaluate the effects of any chosen action as well as the
decision-making process itself. If the expected outcomes are not achieved despite a good quality of
decision-making process, they may need to go back to a previous step and consider other strategies. In addi-
tion, if the confronting ethical problem is solved successfully at this time, nurses need to develop strategies
to prepare for similar problems that arise in the future at three levels: individual, institutional, and commu-
nity/societal.
Table 3. Example excerpts of students’ experiences of applying the integrated ethical decision-making model
Improvement in the decision-making process
– When not using this model, I tended to make a guess rather than utilize ethical theories or principles.
– I had to think about many different aspects while applying the model, and I believe this training will help me more
comprehensively review ethical problems in the future.
– Without the model I would not have gone though such a sound thinking process.
– There was no difference in the final decision whether we applied the model or not. However, our decision-making
processing was very different. Without the model, we approached an ethical problem as if it were a true-false
question. When we used the model, we were able to discover many diverse situations and alternatives.
Improvement in developing and selecting options
– We realized that an option supported by a larger number of ethical principles or rules is desirable. We didn’t know
that when reviewing options without the model.
– I found that some options preferred in terms of short-term outcomes were less desirable in terms of their long-
term outcomes, which I would never have realized without the model.
– I chose an option with more caution and became more confident with my decision.
Improvement in attitudes in ethical decision making
– I was able to better understand a client’s thoughts or feelings while comprehensively exploring reasons for the
problem.
– I was able to clarify my own value systems while reviewing the different goals or preferences of the parties involved.
– I realized how difficult it is for a nurse to reach ethically good or right decisions, because a nurse’s decision directly
affects the life of a client. I almost had a headache when considering the different views of all those involved.
– We were rather upset when we found that each of us had dissimilar perspectives on the given ethical problem.
Understanding characteristics of ethical dilemmas
– I felt uncomfortable that I was not able to find a completely satisfying solution; I had to choose only the best
possible option for a certain ethical problem.
– We had to admit that there were situations in which no option is perfect.
– It was very difficult to choose an option: when we chose the first option, some aspects of other options, which
were incompatible with the first option, appeared still attractive.
Difficulties in developing strategies for achieving ethical goals
– It is complicating to think about possible strategies to fulfill our ethical goals. Although we know what is ethically
right, we were not able to find proper approaches or tools available in clinical settings.
Applicability of the model in future nursing practice
– After learning this model, I thought that my ethical decisions in the future would be more consistent, reflecting my
own beliefs and views.
– At first it took us a long time to reach a conclusion because we were not accustomed to such a comprehensive
consideration when applying all kinds of ethical knowledge. However, it was much easier once we learned the
process of the model, and, as a clinical nurse, I want to use the model in the future.
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Usability of the integrated ethical decision-making model
Twenty student groups in nursing ethics courses reported that the model was easy to understand and follow and
very useful for them to solve the clinical ethical issues. The benefits of using the model were many, and exam-
ple excerpts from the students are provided in Table 3. When applying the model, the number and the diversity
of supporting criteria for their ethical decision and alternatives were greatly enhanced: for instance, the num-
ber of alternatives increased from two to four or five in a majority of the student groups when applying the
model for solving ethical problems. Accordingly, students expressed a stronger confidence with their final
decision and its justification when they applied the structured model for decision making. The students said
that they made ethical decisions based often on their intuition or subjective judgment without the model, but
they were able to make a decision with rationales satisfying more ethical principles or professional standards.
In the process of solving ethical problems using the model, the students said that they approached the clin-
ical ethical problems more seriously and felt stronger responsibility for their decision while they reviewed all
relevant actors’ preferences and possible long-term and short-term outcomes. For example, they said that
they were able to better understand a patient’s perspectives or feelings. Overall, students felt safer because
they believed that the use of the model improved quality of the ethical decision-making process and possibly
its outcomes avoiding hasty decisions.
The students reported that they unexpectedly became aware of their own ethical values and the diversity
of values among their peers while they worked on the ethical problems as a group. Most difficulties were
reported in Step 5 of developing strategies to implement the decision and in Step 6 of developing strategies
to prevent similar ethical problems in the future. Probably students’ knowledge and experience in clinical
practice and its environment were not sufficient for strategy development. However, regardless of using the
model, students found it difficult to apply ethical theories or to deal with ethical dilemmas with no correct
answer. Nevertheless, they said that they would use this model in the future as a RN because it is easy to apply
and because it would help them to be a responsible professional.
Conclusions
An integrated ethical decision-making model was developed based on a systematic review of previous ethical
decision-making models and its pilot-test with baccalaureate nursing students in an ethics course. Despite the
different number of decision-making steps or stages, the reviewed 20 ethical decision-making models sug-
gested somewhat similar logical decision-making processes. However, most decision-making models often
appeared less effective because they did not explain how each stage could be better accomplished or more
considered. Most models focused on process and neglected content, so that a practical use of these models
may be less than useful. Therefore, this study developed an integrated ethical decision-making model con-
sisting of six steps and including critical considerations to satisfactorily accomplish each of those steps. Nur-
sing students reported very positive experiences in applying the model to ethical cases in their ethics course.
This study found that the model presented here can be easily adopted in the teaching of nursing students. It is
similarly expected to be adoptable to solve ethical problems in clinical settings among nurses, especially
neophytes.
Ethical decision-making competency becomes more and more challenging in clinical practice for a
variety of reasons, including the increasing diversity of individual value systems, rapidly changing
healthcare environments, and the complexity of healthcare systems. The best ethical decision should
be determined by putting efforts from all relevant professionals and a nurse should not overlook his
or her responsibility as long as he or she is involved in patient care. A structured ethical decision-
making model does not guarantee ethically right or good decisions because ethical decision making is
not a mechanical process.22 Nevertheless, a structured model does highly likely improve a process and
154 Nursing Ethics 19(1)
154
outcomes of clinical ethical decisions. It is recognized that there is a need for the model to be repeatedly
applied, tested, and refined in both the educational and practical environments.
Funding
This research was supported by the Kyungwon University Research Fund of 2011 (KWU-2011-R172).
Conflict of interest statement
The author declares that there is no conflict of interest.
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Appendix 1. Integrated ethical decision-making model and its applica-
tion with a clinical example
An 85 year-old man with dementia was admitted to a hospital via the emergency room because of aspiration
pneumonia. His wife, who cared for him, said that recently he had been having difficulty swallowing even soft food.
According to a result of a VFSS (video fluoroscopic swallowing study), he had severe dysphasia; so Levin-tube feeding
was recommended to prevent the recurrence of aspiration pneumonia. His physician believed that his dysphasia was
unlikely to be cured because its occurrence was due to dementia. The physician explained to the patient’s wife that
Levin-tube feeding was the most effective way to prevent pneumonia and that any recurrence of pneumonia would
be very risky given the age of the patient. However, the patient’s wife simply refused to insert the Levin tube into her
husband despite understanding the high risk of a recurrence of aspiration pneumonia if he took food by mouth.
Finally the patient was discharged without the L-tube, and in order to lower the risk, his wife was taught how to
prepare food to increase its viscosity and how to position his neck when swallowing food. Nevertheless, he was
admitted again for aspiration pneumonia four months later. He had lost too much weight and had a bed sore on his
coccyx because he had not been taking enough food due to the risk of aspiration. Although his pneumonia was again
treated well, another VFSS showed that his swallowing function had deteriorated. The wife once again refused to
insert the Levin tube, saying that if she did so his quality of life would be poorer and he was old enough to refuse
treatment even if it meant that that treatment would extend his longevity. When a physician asked me to persuade
the wife to change her mind, I was unclear about what would be the best ethical course of action.
Step 1. State an ethical problem
1) Problem statement as a conflict of ethical values:
Avoid a statement using behavioral terms (action-
oriented) or choosing one of two options.
2) Is this an ethical issue? Or, is this a communi-
cation problem, a clinician-patient relationship
issue, or a legal problem?
3) Characteristics of the problem can be assessed
to learn your own perception or attitudes.
A. Temporal urgency (e.g., high, middle, low):
How urgent is the decision?
B. Magnitude of consequences (high, middle,
low): How greatly does the decision affect
the health status and quality of life of the
patient?
C. Does the ethical problem already exist or is
it likely to occur?
4) Do you need further information to compre-
hensively understand the problem or to seek
alternatives or options to solve it?
1) Ethical dilemma between a principle of respect for
patient autonomy and a principle of beneficence for
lowering a risk of aspiration pneumonia, which could
threaten the patient’s life
2) It is an ethical issue.
3) A. Middle
3) B. High
3) C. Already existing problem
4) Yes. For example: 1) What is his decision-making abil-
ity? 2) Is he able to express his desire for treatment and
quality of life? 3) If he is not able to understand or decide
medical treatment for him, is his wife a surrogate who
best knows the patient’s preference? 4) Does his wife
make decisions based on not her own interest, but the
patient’s interest and preference?
(continued)
Park 157
157
Appendix (continued)
Step 2. Additional information collection and anal-
ysis of the problem
– Who are actors involved in this issue and what
information is needed from each?
– If necessary, provide the actors with information
needed to establish their own perspectives and
opinions regarding the problem.
– Biological information (e.g. diagnosis, treatments,
prognosis and expected outcomes), psychosocial
information (e.g. values, cultural backgrounds,
religions, growth, emotional stress), social/his-
torical aspects, or goals preference, values
related to the issue.
Information
Actors
involved
Biological
aspects
Psychological
aspects
Social,
historical
aspects
Goals,
preference,
values
Patient O O O O
Family or
significant
others
O/X O O O
Professionals X O/X O/X O
Institute,
associations,
or society
X X O/X O
Note: O ¼ YES, X ¼ NO
– Who is the ultimate decision maker?
– Is the statement of an ethical problem in Step 1
correct? If necessary, correct them and restate
the problem
For example, we learned the following:
– The patient did not express his preference in medical
care before having dementia.
– His wife is afraid of feeding her husband via L-tube
because she is not sure whether she can do it safely.
– His wife hopes that her husband lives the rest of his life
with dignity and believes that having food via L-tube
seriously damages his dignity.
– Health professionals are responsible to prevent pneu-
monia, and L-tube feeding is a good choice because the
patient can stay at home and his wife will be able to take
care of him.
– Our society highly values both a patient’s right to
choose a treatment (autonomy) and health profession-
als’ duty to provide any necessary treatment. In recent
years, a patient’s right of autonomy is becoming more
established.
– The patient’s wife
– Yes, this is an ethical conflict as stated in Step 1.
Step 3. Develop alternatives and analyze and com-
pare them
– To analyze and compare alternatives, various
aspects need to be considered as follows:
1) Ethical rules (fidelity, veracity, and
confidentiality)
2) Ethical principles (autonomy, nonmaleficence,
beneficence, justice)
3) Ethical theories (utilitarianism, duty-based, vir-
tue ethics, caring ethics) – Options, Outcomes,
Values, and Likelihood (OOVL) Guide may be
useful for applying utilitarianism
4) Professional ethics – codes of ethics, guidelines
for practice
5) Legal aspects
6) Health professionals’ personal conscience or
religion
7) Institute’s or society’s values, guidelines, or
policy
Alternative 1. inserting L-tube after getting consent from
the wife
Alternative 2. respecting her decision and not-inserting L-
tube
Applying utilitarianism, Lewis et al.’s32 Options,
Outcomes, Values, and Likelihood (OOVL) Guide can
be used as follows, using a Likert-type scale.
Short-or
Long-term
Outcomes
Prevention of
pneumonia
Provision
of proper
nutrition
Discomfort
of keeping
L-tube*
Values High Medium Medium
Alternative 1 High High High
Alternative 2 Low Low Low
* negative outcome
(continued)
158 Nursing Ethics 19(1)
158
Appendix (continued)
Step 4. Select the best alternative and justify your
decision
– As a result of analysis and comparison, which
one has a priority among the alternatives?
– Is the chosen alternative consistent with your
own value or institution’s value?
– Think about an opinion that does not conform
to your choice and challenge it
– Assuming a situation when the chosen alterna-
tive was implemented, answer the following
questions.
1) Legal test. Is the chosen option consistent
with law?
2) Front-page test. What if this case were
published in one of the popular newspapers?
3) Gut-feeling test. Is your decision consistent
with your gut-feeling as a nurse?
4) Role model test. Is a RN you respect likely
to make the same decision?
5) Professional standard test. Is your decision
acceptable to the nursing profession?
– We selected the alternative 1: inserting L-tube after
getting consent from the wife.
1) Yes.
2) Yes.
3) Yes.
4) Yes.
5) Yes.
Step 5. Develop strategies to successfully imple-
ment the chosen alternative and take action
– To persuade his wife, you may let other family members
participate in decision making. For example, their chil-
dren may agree with you and may be able to persuade
their mother.
– Health professionals need to make sure his wife clearly
understands his medical condition as well as the benefits
and risks of L-tube insertion.
– To lessen his wife’s burden of L-tube care, you can ask
their children to participate in caring for their father, or
arrange a home nurse as necessary.
Step 6. Evaluate the outcomes and prevent a similar
occurrence
– Evaluate the outcomes of the chosen action and
the decision-making process
– Strategies for preventing a similar problem in
the future
1) At an individual level
2) At an institutional level
3) At the community or societal level
1) Better communication of each other’s values between
healthcare professionals and a patient/family; providing a
patient/family enough information needed to under-
stand the necessary medical treatments
Park 159
159
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Case Study – Our Pregnant Daughter Didn’t Want This.
October 31, 2021
Advance Care Planning
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Case Studies
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Case Study – Our Pregnant Daughter Didn’t Want This
Case Study: Our Pregnant Daughter Didn’t Want This…
By Tarris Rosell, PhD, DMin
Twenty-nine year old Janet and her husband Jack were driving home from her ob-gyn appointment when tragedy struck. Another driver, elderly and distracted by an incoming text message, ran a red light and T-boned Janet and Jack’s Mini-Cooper. Both young people sustained severe injuries.
Jack died enroute to the hospital. Janet survives, having escaped injury except to her head; but that was unfortunately massive. Her physicians now say, a month after the accident, that the prognosis is grim. The best one could hope for— or perhaps the worst—is continuation for some time in a persistent vegetative state.
Just before leaving the doctor’s office, Janet had sent a jubilant text message to her parents. “Guess what?! We’re pregnant!!! ”
So Janet was pregnant—and prescient. Unlike most young adults, Janet had thought about mortality in advance of this accident. She is, or was, a nurse. She had gone to continuing education workshops about end of life care and advance care planning. Janet then had completed her own
advance directives
some months ago, naming Jack as her primary agent and durable power of attorney for healthcare decisions. She named her parents as secondary agents.
Janet also had completed, with notarized signature, a healthcare treatment directive. Among her directives was a clear, handwritten statement about life prolongation if she were, somehow, “to end up in anything like PVS, from which I am not apt to recover.” Janet had written that, in such a condition, “I do NOT want my life to be extended by means of medically assisted nutrition and hydration, ventilator, or other life support.”
And then it happened.
With Jack gone, treatment decisions are left up to Janet’s parents. They both are thoughtful people, healthcare professionals also, who take very seriously their difficult responsibility of acting as surrogates on Janet’s behalf. After consulting her physicians, other family members, and even their priest, a decision is made to stop everything except palliative care. Janet’s parents had received a copy of their daughter’s advance directives, and they have determined that this is what she would have wanted, what in fact she had conveyed with such tragic prescience. Plans are made to transfer Janet to a hospice unit in another part of the hospital. It would take place the following day.
That evening, a resident physician notices in the patient’s chart that Janet is pregnant. Probably about nine weeks, it appears. He wonders if this matters, legally or ethically or religiously, for his patient’s transfer to hospice, especially when Janet is not imminently dying otherwise. The resident does a bit of online research and learns that in the State of Kansas, a woman’s healthcare directives about “withholding or withdrawal of life-sustaining procedures in a terminal condition” may not legally be in effect while pregnant.
“The declaration of a qualified patient diagnosed as pregnant by the attending physician shall have no effect during the course of the qualified patient’s pregnancy” (KSA 65-28, 103, (4)B). A note in the patient’s medical record the next morning references this statute, with a question about how it potentially impacts the impending transfer to hospice care. When the attending physician reads the note, she calls Janet’s parents and says hesitatingly, “We have a bit of a problem here. It appears we may need some legal assistance, perhaps an ethics consultation, and must postpone Janet’s transfer of care.” The doctor explains further what her young resident colleague had discovered and questioned.
The parents had spent a sleepless night anticipating today. It would be the hardest thing they’ve ever done, and yet the right thing in keeping with their daughter’s wishes. Now they can’t believe what they’re hearing.
Postpone? Ineffective advance directives? Continued life support? Did the doctor really say that? That there may even need to be surgery for a feeding tube and a tracheostomy while this legal glitch is being discussed and gets clarified?
Almost in unison, Janet’s mother and father protest, “But, Doctor, our daughter didn’t want this!”
Questions for discussion
1. What should be done now for Janet and her parents, and on what grounds?
2. What values underlie the statute making a pregnant woman’s healthcare treatment declarations of “no effect” while pregnant?
3. Do you agree or disagree with this statute, and on what grounds?
4. What decision would you be making as Janet’s parental surrogate, and why?
5. Ought someone to be a surrogate for Janet’s fetus, or not? And why or why not?
advance directives
reproductive rights
withholding and withdrawing
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Exam Content
1.
Top of Form
Review
“An Integrated Ethical-Decision-Making Model for Nurses” from the
University Library Readings
.
An integrated ethical decision-making model for nurses article
Apply the ethical decision-making model in the article to access this case study from the Center for Practical Bioethics:
Our Pregnant Daughter Didn’t Want This…
Review the Questions for Discussion following the case.
Follow the steps provided in the model, including the following:
Step 1: Explain the ethical issues, other relevant ethical considerations, and ethical principles relevant to this case study and how they affect the nursing practice.
Step 2: Collect and analyze additional information related to this case study, including researching and explaining any legal considerations.
Step 3: Develop alternatives (different options) and compare them.
Step 4: Determine your position and justify it:
· What specific actions should be taken to ensure an appropriate outcome?
· Why is your position important, needed, or beneficial for vulnerable populations?
· Are the legal and ethical responsibilities in alignment with each other? If they are not in alignment, how does your position deal with that conflict?
Step 5: Find strategies to implement the plan:
· What ethical arguments could you use to persuade someone who disagrees with your position?
Format your assignment as an 875- to 1,050-word paper.
Cite at least 3 peer-reviewed sources published within the last 5 years.
Note: At least 1 of the sources should provide evidence for your resolution recommendation or plan of action.
Include an APA-formatted reference list.
Submit your assignment.
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