see below ….
EThICal dECISIoN-MakING:
a fraMEWork for uNdErSTaNdING
aNd rESolvING MENTal hEalTh
dIlEMMaS
–Marna S
.
Barrett, PhD
Clinical Associate Professor of Psychology in Psychiatry
University of Pennsylvania Perelman School of Medicine
2
Think about It!
• Ethical dilemmas are inherently troublesome, primarily because they involve at least two compet-
ing yet equally “right” choices rather than a right versus wrong choice.
• Distinct from other branches of medicine, psychiatry raises unique challenges for ethical decision-
making. Only in mental health are we asked to determine a person’s competence, restrict a per-
son’s right to self-determination, participate in legal decisions about a person’s culpability, and
engage with society in a reciprocal relationship of influence.
• Ethical principles such as autonomy, beneficence, nonmaleficence, fidelity, justice, and empathy
are ideals to which we strive. Although useful for understanding the complexities of a dilemma,
they are not sufficient for problem resolution.
• A framework for ethical decision-making is imperative for developing a consistent and effective
personal standard for resolving ethical dilemmas. Key elements of such a framework include identi-
fying and clarifying the issue, determining whether the situation is a “right versus wrong” or a “right
versus right” dilemma, evaluating the principles involved, creating a “trilemma,” weighing benefits
and burdens, consulting, considering possible outcomes, making document decisions, and review-
ing and reflecting on the process.
Ethical dilemmas are among the most difficult struggles we face. Whether in our professional or personal
lives, we are confronted with decisions about what is right, fair, kind, and just. Within medicine, ethical
dilemmas are more pronounced because of competing concerns such as benefit versus harm, the rights
of individuals versus the rights of others, patient competency, patient versus hospital obligations, or
truth versus kindness. In all ways, we are encouraged by our profession to strive toward the ideals of
“compassion and respect for the inherent dignity, worth, and uniqueness of every individual” (American
Nurses Association (ANA, 2001, para. 16). A formal code of ethics is what enables professionals to make
clear to society the ethical obligations and duties that can be expected from us.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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18 Nursing Ethics in Everyday Practice
Being ethical, however, involves more than simply adhering to a professional code of ethics; it requires
the infusion of personal virtues and ideals. For example, two nurses can follow the same mandate to respect
others, yet someone who holds the personal ideal of autonomy and self-determination is likely to uphold a
patient’s ideas, beliefs, and decisions, even if these are in conflict with the opinion of a colleague. Differing
personal values help explain why conflict so frequently arises between two ethically sound individuals.
Although the Code of Ethics for Nurses (ANA, 2001) guides and directs our thinking about ethical be-
havior, it provides little help in determining a course of action we should take when faced with a specific
dilemma. In fact, what makes an ethical dilemma a dilemma is that two possible solutions exist, neither of
which seems fully acceptable. Without some type of framework to guide the decision-making process, we
are left to our own feelings, beliefs, hunches, and best bets about the “right” action.
In this chapter, I first discuss the general nature of decision-making, how decision-making differs in the
context of a moral dilemma, and why a model of moral decision-making specific to mental health issues is
needed. I then present the organizing principles of ethics and how they can be used to inform decisions. I
then cover five models or frameworks for decision-making that are useful in addressing and resolving ethi-
cal dilemmas across contexts or situations. I end with a case presentation using the practice-based model
for decision-making, one that I have found to be comprehensive, easy to use, and widely applicable to ethi-
cal issues in mental health.
decision-Making
When faced with any decision, we generally follow three steps.
1. We identify the various alternatives for action. So, if I’m unhappy in my current position, I might
consider quitting, moving to another hospital floor or unit, working on a different shift, or return-
ing to school.
2. After all possibilities are identified, we review the potential outcome of each. For example, quitting
might present financial difficulties, working a different shift might not be feasible given childcare
responsibilities, and moving to another floor would mean switching from geriatrics to medical/
surgical.
3. Having considered all the possibilities and outcomes, we make a choice between the alternatives
based on personal values and preferences. For example, although I am unhappy in my current
position, I value the time with my children and believe that I am especially gifted in working with
older patients. Therefore, I decide to remain where I am and look for ways to change the environ-
ment so that I feel happier.
But how does decision-making related to moral or ethical issues differ? First, the dilemmas or uncer-
tainties concern moral issues and, as such, are inherently personal. Although societies typically hold to a
set of moral values, such as honesty, respect, kindness, fairness, and freedom, the range of values and the
importance given to a particular value are unique to each individual. Whereas some people value honesty
above all else, others value tolerance and appreciation of differences; and still others value faith, integrity,
personal happiness, or hard work. Because morals influence our behavior, they are considered personal
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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19Chapter 2: Ethical Decision-Making
characteristics and thus carry emotional weight. When a dilemma arises that involves moral issues, we are
faced not only with choosing among various alternatives for action but also with the emotion-laden values
associated with any choice. In fact, the need for rationality (or reduction of emotion) in resolving ethical
deliberations is the second factor unique to ethical decision-making.
Let’s re-examine the dilemma about work (presented earlier) with the knowledge that my unhappiness
is primarily related to conflict with my supervisor. Although I am someone who is deeply proud of my
work and feels a strong commitment to the people and hospital where I work, I respect authority and find
it hard to confront my supervisor. With this information selecting a course of action becomes more com-
plicated. Quitting my job would risk financial hardship and create a tension between my values of respect
for authority and commitment to others. Considering a change in shift could create a conflict between my
need for happiness and my commitment to fellow employees and to my children. However, a move to an-
other floor in the hospital would allow me to maintain my values and meet the needs of my family. Thus,
situations that involve moral and ethical concerns invoke such emotional connections to the issue that
rationality and rigor in making any decision are warranted.
Mental health issues complicate the picture even more. Unlike any other aspect of medicine, psychiatry
has unique moral and ethical issues (Fulford & Hope, 1994; Radden, 2002). In no other branch of medi-
cine are assessments of the competency of patients to make decisions about their care required. Medical
philosophers such as Thomas Szasz (1959) have argued that restricting a person’s right to self-determina-
tion is worse than slavery. Yet psychiatrists are typically asked to make such decisions so that other medi-
cal specialists can proceed with a particular course of action.
Mental health disciplines are also unique in that they play a role in legal issues—competency to stand
trial, determination of sanity, or custody issues. Other than expert testimony, discussions of an individu-
al’s physical or medical health have little place in the courtroom and are not influential in determining
legal outcomes. Mental health problems, in contrast, frequently influence the courts in terms of sentenc-
ing, guardianship, or responsibility for action.
Case Study 2 .1
Jim, a 65-year-old white man with beginning dementia, was hospitalized with diverticulitis. He
was operated on and had an unremarkable recovery. As part of his discharge planning, he was
to be given Oxycontin for pain. Jim did not think there would be much pain and didn’t want to
take medication for fear that he would become dependent. Jim had recently seen a television
show about addiction to painkillers and feared it might happen to him, since there was sub-
stance abuse in his family. Jim refused the prescription for Oxycontin and was told that he could
not be discharged without it. The more the nurse tried to get Jim to accept the prescription
(whether or not he actually took the medication), the angrier and more suspicious he became
about the reasons for the medication.
This case presents several ethical challenges. For instance, should the nurse continue to deny
discharge to Jim unless he accepts the prescription, or should the policy be waived? Although
discharge planning is routinely handled by the nurse, should Jim’s doctor be notified of the situ-
ation and asked to override the order for pain medication? Given Jim’s problems with reasoning
(i.e., beginning dementia), it might be useful to spend a few minutes educating him about the
appropriate and safe use of pain medication. However, what should be done if he still refuses
the prescription?
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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20 Nursing Ethics in Everyday Practice
Additionally, a reciprocal relationship of influence exists between society and mental health. The Di-
agnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric
Association (2000), offers a nosology for mental health disorders that determines the standard criteria by
which behaviors are considered abnormal. By establishing such criteria, psychiatry influences what be-
havior is seen as problematic, justifies the need for treatment, and affects third-party payment. Secondary
effects of behavioral labeling are social stigma, forced treatment, isolation, and marginalization.
A recent example of the reciprocal influence with society is the diagnosis ofAsperger’s syndrome. Al-
though considered a part of the autism spectrum disorders, Asperger’s syndrome was treated as a separate
diagnosis in the DSM-IV because of the distinct symptomatic picture. This distinction resulted in greater
awareness of the disorder, improved funding for research, and reduced stigma (Hamilton, 2010). How-
ever, in considering revisions for the new DSM-5, researchers have suggested that Asperger’s syndrome
be moved back under the rubric of autism spectrum disorders, because the basic difficulties with social
engagement and language development are the same (Macintosh & Dissanayake, 2004). Not surprisingly,
this suggestion has been met with considerable resistance and public outcry. Although many believe that
the services available to individuals with Asperger’s syndrome would increase, the fear is that such a move
would damage the considerable progress made in terms of reduced stigma and social acceptance for this
disorder (Parenting Aspergers, 2010).
Ethical decision-making is, therefore, the attempt to decide between at least two competing courses of
action that is complicated by personal values, strong emotions, and unclear guidelines. When occurring in
the context of mental health, ethical decision-making is further complicated by the social, personal, legal,
and organizational filters through which the situation must be examined. For these reasons, a framework
to guide and inform ethical decision-making is crucial.
Ethical Principles
Ethical principles are the standards that guide and promote the values held by a society, organization, or
individual in determining what is right or wrong. Having their roots in ancient Greek philosophy, these
principles are fundamental to Western bioethics (Beauchamp, 1999; Beauchamp & Childress, 2001) and
form the basis for professional codes of ethics (Bloch & Pargiter, 1999).
• Autonomy refers to individuals’ rights to make choices about the nature and direction of their
life without interference from others. Respect for autonomy means that we recognize and
appreciate an individual’s perspective and capacities to hold certain views, make certain choices,
and take action based on personal values, beliefs, and ideas.
• Beneficence is essentially seeing to the welfare of others. In medicine it requires us to act in ways
that benefit others or are in their best interest. For example, patients benefit when we show mercy,
kindness, or charity to them by alleviating their pain and suffering. Beneficence can also extend
to aid we give in finding financial assistance or helping patients to gain access to health care.
• Somewhat in concert with beneficence, the principle of nonmaleficence requires action that does
not bring harm to or hurt others. The balance between nonmaleficence and beneficence is one of
the most common dilemmas within medicine, because most interventions or treatments involve
the weighing of benefits versus risks.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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21Chapter 2: Ethical Decision-Making
• Fidelity refers to the act of faithfulness or loyalty. It is the trustworthiness people show in
meeting their duties and obligations. Within medicine, fidelity also encompasses the trust
patients place in us, the reliability and integrity of our treatments, and the manner in which
these treatments are administered. Fidelity is of such importance that some have argued it is the
foundation upon which all other ethical imperatives depend (Radden & Sadler, 2010).
• Justice can represent two types of behavior. Equal justice means treating all people the same
without regard to any personal characteristic or behavior. Fairness refers to actions in which
equal distributions of benefits, costs, and risks are made between individuals. For example, is a
transplant list just in how it prioritizes individuals? Is it fair that someone of wealth can purchase
a needed organ when others of lesser means are unable to do so?
• Although not always discussed as one of the fundamental ethical principles, empathy is a prin-
ciple of behavior valued in medicine. Defined as the capacity to recognize and share the experi-
ence of others, empathy demonstrates an understanding of people and identification with their
feelings that has been shown to affect outcome.
Case Study 2 .2
Lisa, a critical-care nurse, is caring for Rochelle, a 73-year-old woman suffering from diabetes
and multiple internal injuries following a serious motor vehicle accident. Although Rochelle had
expressed to her husband and several friends a desire to not live in a situation as she was cur-
rently, her husband was persuaded by the children to do everything possible to sustain her life.
Rochelle’s husband has privately expressed to you his concern that her wishes are not being
followed but feels he cannot disregard the wishes of their children.
What ethical dilemmas are raised in this case example? One challenge is whether or not Lisa
should tell the doctors about Rochelle’s stated desires for limited life support, since it is hearsay
from her husband. Should Lisa discuss the situation with Rochelle’s children? Should Rochelle’s
treatment be altered? Each of these dilemmas involves competing ethical principles. For ex-
ample, underlying the decision to discuss Rochelle’s desires with her doctors are the principles of
beneficence (benefit to Rochelle by making her wishes known), fidelity (duty to disclose known
information), and nonmaleficence (don’t harm Rochelle by giving her treatment she would not
want). However, in regard to any decision to alter treatment, the principle of beneficence (do
what is in her best interest) may conflict with the principle of nonmaleficence (do her no harm).
What other conflicts do you see between ethical principles?
Ethical principles are ideals to which we aspire and encourage us to act in ways that better us as
individuals and as a part of society. They provide a level of organization to our thinking about what is
moral or right and help inform ethical decisions (Beauchamp & Childress, 2001). In fact, the reason
ethical situations are so challenging is precisely because these principles underlie our thinking, and
individuals differ in what is valued. However, it should also be recognized that ethical standards and ideals
are not obligations. We have no responsibility to adhere to them, and they should not form the basis for
imposing sanctions. That said, let’s now examine the ways these principles can inform our decisions.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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22 Nursing Ethics in Everyday Practice
Case Study 2 .3
Betty is a 45-year-old Caucasian female with bipolar disorder, type II, who works as a nurse
practitioner for Tisdale Internal Medicine. Her mood state has remained relatively stable for the
past 15 years, with brief periods of moderately severe depression followed by mild hypomanic
episodes. Six months ago, Betty suffered the loss of her mother, with whom she had a close rela-
tionship. She seemed to handle the loss well, but over the past month has become increasingly
irritable, interrupting conversations and “talking over” others. She is currently full of energy, has
several new ideas for improving office functioning, and feels the changes should be made im-
mediately. Her demand for change has created tension among the staff, and patients have
complained about her abrupt and somewhat dismissive behavior. Her boss, Dr. Mitchell, is aware
of her recent loss, as well as her chronic mental health problems.
Dr. Mitchell is faced with the dilemma of determining how best to respond to Betty’s behavior.
Should Dr. Mitchell talk with Betty about her behavior, or should he intervene with staff? If he talks
with Betty, what does he do if she refuses to acknowledge her behavior as problematic? How
much of her history can be shared with the staff? To what extent does confidentiality restrict his
range of responses? Consider these questions as we review several approaches to ethical di-
lemmas in the following section.
Ethics Principles Inform decisions
Though meant to inspire us, ethical principles, such as those listed previously, also provide a basis for
our thinking about ethical decisions. For example, the decision about how much to tell people prior to a
surgical procedure, vaccination, or research participation (that is, informed consent) is grounded in the
principles of autonomy, beneficence, nonmaleficence, justice, and empathy. Since the time of Aristotle
and Plato, philosophers have argued about various ways to approach ethical situations that most benefit
society. For example, from an Aristotelian perspective, society benefits when we recognize and further the
goals we share in common, yet maintain respect for and value the freedom of individuals to pursue their
own goals. Referred to as the fairness or justice approach, decisions are based on a determination of which
action treats people most fairly.
Expanding this idea a bit further, the common good approach asks us to consider which action con-
tributes most to the quality of life for the people involved. For example, of the number of ways to address
the situation with Betty (Case Study 2.3), a common good approach would suggest that Dr. Mitchell talk
with Betty about the effect her behavior has had on the office and encourage her to take time off and seek
treatment.
A second major approach to ethical dilemmas is the act utilitarian or ends-based model. Utilitarian
thinking requires consideration of which action brings the most benefit to the most people and incurs
the least harm. Immanuel Kant was the main proponent of this approach and argued that in aspiring
to higher principles, we need to consider our duties to others as well as to ourselves. If our motives are
moral, then the outcome is considered moral and right. Applying this approach to the situation with Betty,
Dr. Mitchell might decide to intervene more directly because of concerns about his patients as well as the
staff. He could talk with Betty about her behavior and determine whether she needed to get treatment,
if she was not already doing so. Although Dr. Mitchell values autonomy, in trying to balance the greatest
benefit with the least harm he decides to override Betty’s dismissal of the problems and calls her family.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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23Chapter 2: Ethical Decision-Making
A slightly different perspective to the ends-based model is referred to as rule utilitarianism. From this
perspective, decisions are based on how much good is done by a particular action in regard to a rule or
law. The premise is that the rules of society are in place to maintain order and are therefore to be respected
and valued. For example, euthanasia, the ending of life to relieve pain and suffering, is legally wrong in this
country. In deciding whether or not to continue life support of a comatose patient, a person following rule
utilitarianism would consider how much society would benefit if life support were removed against the law.
A third major approach to ethical decision-making is rule-based or deontological thinking. This ap-
proach requires that we consider an action based on whether or not we would be comfortable with our
action becoming law. In other words, the morality or ethic of an action is judged not on consequences, but
on the principles that underlie the action. For example, in resolving the dilemma with Betty, Dr. Mitchell
would determine a course of action consistent with his morals and values and one with which he would be
comfortable as a standard for action.
Focusing more on individual character, the virtue-based approach to ethical decision-making encour-
ages us to act in ways that are consistent with the person we want to be. Rather than focusing on the results
of any action, virtue-based ethics focuses on becoming a person of good character. If Dr. Mitchell, in Case
Study 2.3, held to a virtue-based approach, he might ask, “What kind of person should I be?” or “What ac-
tion will promote the development of high moral character in me and my community?” or “If I take this ac-
tion, will I become more like the person I want to be?”
The fifth major approach to ethical dilemmas is based on the principle of care (that is, the golden rule).
Care-based thinking demands that we act in ways consistent with how we would want others to act toward
us. This perspective considers inequalities in relationships, and priority is given to humane treatment that
upholds the respect we all deserve as human beings. Applying this approach to the ongoing example of
Betty, Dr. Mitchell would likely seek to understand how he would feel if he were Betty and base his decision
for action on this understanding. Therefore, he might decide to talk with Betty about her behavior, help her
to appreciate the negative effects brought on by the behavior, and together determine a course of action.
Why Are Ethical Decisions So Difficult?
Given the usefulness of ethical principles in informing decision-making strategies, why do we struggle
so with these issues? Rushworth Kidder, in his book How Good People Make Tough Choices (1995), has
articulated a simple yet poignant answer—most ethical dilemmas are not struggles of right versus wrong,
but right versus right. Most of us have a fairly clear sense of what is right and wrong. Lying, cheating, and
stealing are wrong. Respecting others, telling the truth, and being kind are right. However, at times we
struggle with even these issues. For example, should you tell a patient about the availability of less invasive
procedures when the physician they have seen always recommends surgery? Should Dr. Mitchell disclose
his concerns about Betty to her family?
Despite such questions, most ethical dilemmas leave us unsure about a particular course of action pre-
cisely because they involve two competing “right” choices. For example, upholding patient confidentiality
is right. However, breaking that confidentiality if it is for the protection of others (for example, HIV status,
child abuse) is equally right. If you break confidentiality, the patient might no longer trust you and the
therapeutic relationship will likely be damaged. If you don’t break confidentiality, however, others might be
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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24 Nursing Ethics in Everyday Practice
hurt. Unfortunately, few clear legal mandates for taking a particular course of action exist, and our profes-
sional codes of ethics offer little in the way of specific guidelines for resolving dilemmas.
four Paradigms underlying right versus right dilemmas
1. Truth versus loyalty
2. Individual versus community
3. Short-Term versus long-term goals
4. Justice versus mercy
One way to begin to understand why “right versus right” dilemmas are so problematic is to recognize
that often underlying these issues are competing moral paradigms. For example, being truthful is right
and being loyal is equally right. Consider a scenario in which you’ve become aware that your agency is
billing Medicare for therapy sessions that are not conducted in person, but over the phone. Providing
some sessions by phone is the only way the psychiatrist can offer immediate care to patients in need. The
dilemma, however, is whether you should be truthful and disclose the practice to Medicare or appreciate
the efforts of the psychiatrist to provide care and maintain loyalty to the physicians and agency.
Another paradigm often underlying ethical dilemmas is the tension between an action that benefits
the individual versus one that benefits the community. In my work with patients having bipolar disorder,
I often struggle with the decision about hospitalization. Do I respect the autonomy and self-direction of
the individual to decide whether or not hospital support is needed to control the manic behavior, or do
I restrict his or her autonomy in favor of beneficence and decide that hospitalization is necessary for the
welfare of the patient and community? This scenario might also be viewed as a struggle between benefi-
cence and nonmaleficence. That is, do I help or harm the patient by allowing continued interactions that
increase the likelihood of arguments, fights, uncontrolled spending, or other high-risk behavior? Is there a
way I can help the patient, respect autonomy, and reduce the risk of harm? These are the issues that cause
us discomfort and often lead to disagreements with others.
A third competing moral paradigm is that of short-term versus long-term goals. In my own life, decid-
ing whether I should spend a Sunday afternoon writing papers that would further my career (a long-term
goal) or spend an enjoyable day with my family (a relatively short-term goal) is an almost routine struggle.
In the previous scenario about Medicare, the dilemma of greatest discomfort for the nurse might not be
truth versus loyalty, but the conflict between her immediate need for employment (that is, I might be
fired if I disclose the billing practices) and her long-term feelings about personal character (that is, I am
becoming a bad person if I stay quiet and do not disclose something unethical). This situation highlights
another important issue in understanding ethical dilemmas in that one issue can often be complicated by
multiple competing paradigms.
One final paradigm often presenting itself in ethical dilemmas is that of justice versus mercy. This
struggle is frequently at the heart of many jury deliberations. For example, should someone with schizo-
phrenia be held accountable for his or her actions if he or she chose not to take prescribed medication?
Should the sentence be lessened simply because of the diagnosis? The justice versus mercy debate is also
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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25Chapter 2: Ethical Decision-Making
central to decisions about removing life support or assisting the death of a terminally ill patient. Provid-
ing needed medical care is right and fair, and showing mercy by allowing a person to die with dignity is
equally right and fair.
Although these are just a few of the more frequently occurring competing moral paradigms, this discus-
sion clarifies why ethical dilemmas are so difficult and why we often disagree with respected friends and
colleagues when faced with such a situation. Unfortunately, knowing why ethical issues are problematic
does not get us any closer to knowing how to resolve them. Although professional codes of ethics, laws,
and our own moral compass provide some guidance, they do not help in resolving the majority of issues
we face, particularly in the area of mental health. Not knowing how to act when confronted with the gray
areas of ethics is one of the main reasons I began to explore models of decision-making used in philosophy
and business, with the hope that these might be applicable to mental health dilemmas.
Models of Ethical decision-Making
A number of frameworks are useful in guiding decision-making; however, five models seem particularly
appropriate when facing mental health decisions. These include the standards-based model, the principles-
based model, the virtues-based model, the moral reasoning-based model, and the practice-based
model. As a way to better understand and appreciate the strengths and limitations of these approaches,
presentation of each model will incorporate discussion of the model’s relevance to Case Study 2.4.
Case Study 2 .4
Mr. Stevens is a 66-year-old divorced Caucasian man living alone. He has three grown children
who live outside the state. Until 2 years ago, Mr. Stevens worked as a high school English teacher
at a private school where he had been employed for 35 years. He took early retirement because
of ill health and recently underwent cardiac bypass surgery for several blocked arteries. His re-
habilitation following surgery went well, although he developed a severe depression during his
stay in the rehabilitation facility. He has few friends and now is even more withdrawn, remaining
isolated in his apartment watching TV. His financial situation has worsened, because he has been
unable to find part-time employment and has little in savings. At a recent visit to his cardiologist,
he mentioned to the nurse practitioner, Sophia, that he does not like taking “so many pills” and
sometimes misses a dose. In passing, he mentioned that he would be better off if he had another
heart attack and died. When Sophia suggested he speak with a mental health professional, Mr.
Stevens said that he does not believe he is depressed, but just “worries some.” He then stated
quite adamantly that he did not want to burden his family with concerns of his situation.
Sophia is faced with several issues. Should she intervene with Mr. Stevens’ family? Is treatment
needed for Mr. Stevens? Is hospitalization warranted? Do social services need to be involved?
How should Sophia handle questionable compliance with treatment? How might his recent sur-
gery have influenced the depression, and does this impact her decision for intervention?
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26 Nursing Ethics in Everyday Practice
Standards-Based Model
The standards-based model for decision-making rests on the assumption that rules, laws, and policies
provide the best basis for determining action. By holding to a standard set of rules for conduct, few
situations are seen as ambiguous, and the only question to ask oneself is whether or not the situation
warrants deviation from those rules. From this perspective, the first step in making a decision is
to determine the primary dilemma. This might seem somewhat intuitive, but situations are often
complicated by the presence of multiple clinical, social, legal, and ethical issues that often cloud our ability
to appreciate the main dilemma to be addressed. For example, the case of Mr. Stevens involves issues
related to suicidal thoughts, depression, the taking of medication, financial hardships, and lack of insight.
However, the primary issue is whether or not to force some type of mental health treatment.
Standards-Based Model
1. Determine the primary dilemma.
2. What standards apply?
3. Determine a course of action.
4. Is there a reason to deviate?
Once we identify the key issue, the second step we take is to specify the standards that apply to the
situation and determine whether we have reason to deviate. In Mr. Steven’s case, the standard rule of care
would be to arrange for a mental health appointment and follow up with him regarding compliance. Hav-
ing determined the course of action, we can now ask if we have any reason to deviate from this standard.
At this point, the model often fails us. For example, how severe does Mr. Stevens’ depression have to be
before we take a different action? Is his social isolation and firm decision not to inform his family enough
to warrant deviation? Do we need to consider his denial of depression? With these questions in mind, we
can examine a second model.
Principles-Based Model
A principles-based approach to decision-making relies on the philosophical principles of autonomy,
beneficence, nonmaleficence, justice, loyalty, and empathy to guide our ethical thinking. There are four
major steps in a principles-based approach: clarify the dilemma, evaluate the situation, decide on a course
of action, and act. As with the standards-based approach, one of the first steps in addressing any dilemma
is determination of the primary issue. In the example of Mr. Stevens, the key dilemma is whether or not to
force some type of mental health treatment.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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27Chapter 2: Ethical Decision-Making
Principles-Based Model
1. Clarify the dilemma.
2. Evaluate the ethical principles/factors involved.
3. Decide on a course of action.
4. Act.
Having identified the primary problem, the principles-based approach probes more deeply into the
issue and requires consideration of the ethical principles and values involved. In the case of Mr. Stevens,
the underlying principles are autonomy (respecting his right to make decisions about his care), benefi-
cence (act to benefit him), loyalty (to Mr. Stevens), truthfulness (to Mr. Stevens’ family), and empathy.
Knowing which principles are involved can help us clarify the dilemma and better evaluate the factors
involved. For example, Sophia, the nurse practitioner, might need to ask Mr. Stevens for more informa-
tion about why he doesn’t want his family involved and how he understands his “worries,” to distinguish
facts from beliefs and opinions. This information can also help in weighing the benefits and burdens of
any particular course of action, such as whether Mr. Stevens should be started on medication, his family
should be notified, or social services should be contacted. Because the principles-based approach focuses
on ethical principles, deciding on a particular action involves prioritizing of principles, which might differ
between individuals. For example, Mr. Stevens’ cardiologist might hold beneficence as primary, whereas
Sophia might regard autonomy as paramount, thereby leading to differing decisions for action. In this
case, considering the worst case scenario and potential consequences of a specific choice might be helpful,
although a decision still might not be reached. The inability to resolve dilemmas because of competing
ethical priorities leaves us in no better position than before we examined the dilemma and is a significant
limitation of the principles-based model.
Virtues-Based Model
The virtues-based model considers that our dispositions and habits enable us to act according to the
highest potential of our character and on behalf of our values. In other words, the kind of person that I
am and strive to be determines how I act. From this perspective, we ask two major questions in dealing
with an ethical dilemma: Which of X, Y, or Z choices are most consistent with my values or virtues?
What kind of person will I become if I take X, Y, or Z action? Recall that virtues encompass behaviors or
characteristics such as autonomy, beneficence, empathy, fidelity, justice, and nonmaleficence. In regard
to the situation with Mr. Stevens, Sophia would be encouraged to examine her personal values and
determine which course of action is most consistent. If she prides herself on being an empathic person
who respects individual rights, Sophia might be more inclined to arrange for treatment or hospitalization
for Mr. Stevens than to involve outside agencies or his family. However, if she holds strongly to
truthfulness and connection to others, Sophia might be more likely to alert Mr. Stevens’ family to his
condition and encourage Mr. Stevens to involve them in any discussions about treatment.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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28 Nursing Ethics in Everyday Practice
virtues-Based Model
1. What kind of person will I become if I take a particular course of action?
2. What course of action is most consistent with my virtues?
3. Act accordingly.
Either approach would be appropriate and “right,” although vastly different outcomes are likely to re-
sult. Therefore, one of the major limitations of the virtues-based approach is that it relies on the virtues of
each individual to determine a particular course of action. If the dilemma involves only a single person,
the model can be useful. However, the greater number of people involved in the process, the more difficult
it is to reach agreement, because everyone differs to a greater or lesser extent in the virtues to which they
strive.
Moral Reasoning-Based Model
The moral reasoning-based approach to ethical dilemmas, proposed by Jones (1991), argues that
individuals reason on a higher moral level when the perception of moral intensity increases. In other
words, the extent to which an individual is immersed in the ethical dilemma, the perceived importance
of the issue (that is, risk for harm, social consensus), the immediacy of action, and the degree of impact
(amount of harm or benefit) all factor into the level of moral reasoning used in resolving a dilemma.
Given that ethical decision-making requires considerable time and effort, Jones argues that we rely
on lower levels of moral reasoning (for example, self-interests, social expectations) when an issue is
less intense and higher order reasoning (for example, ethical principles, abstract thinking) when the
perception of intensity is high. Stated more simply, when the stakes are high, we give greater thought in
determining a course of action.
Moral reasoning-Based Model
1. Recognize the moral issue and determine that action is needed.
2. Determine level of involvement.
• Individual & situational variables
• Factors of opportunity
3. What is the effect of the decision on others?
• Impact an individual or group
• Likelihood of harm
• Closeness to the issue
• Agreement with social norms
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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29Chapter 2: Ethical Decision-Making
Relying on the moral reasoning-based model, how might Sophia approach the situation with Mr. Ste-
vens? What level of moral intensity might she perceive? As with several of the models, we must first rec-
ognize that a situation involves a moral issue requiring us to act. The moral reasoning approach then asks
that we determine our level of involvement in the dilemma by assessing individual and situational factors.
For example, because the situation with Mr. Stevens involves issues related to his care, both Sophia and
the cardiologist are likely to be involved in the decision-making. However, because Mr. Stevens disclosed
his feelings to Sophia and she has a relationship with him, she is in a better position than the cardiolo-
gist to intervene. The next major step is to determine the effect of any decision on others. For example,
although Mr. Stevens’ family would be affected if the decision was made to contact them or pursue hospi-
talization, the main person affected by any decision is Mr. Stevens. Also involved in determining the effect
of a decision is whether harm might come to Mr. Stevens as a result. Although physical harm is unlikely,
Mr. Stevens could well suffer from forced treatment, unwanted interactions with his family, or challenges
to his self-esteem. In regard to the issues, the need for treatment and potential for self-harm are important
social concerns, and a decision to contact Mr. Stevens’ family, refer him for treatment, or hospitalize him
if at risk for suicide would be deemed by most of society as appropriate courses of action.
Two final considerations are whether the decision needs to be made immediately and the severity of its
impact. The question of immediacy is fairly straightforward. Mr. Stevens does not report clear intent or
plan for suicide and is functioning well, albeit with some limitation. So those involved have time to con-
sider various options and to even meet with Mr. Stevens again. Despite these less immediate concerns, the
decision does have fairly significant consequences for the doctor-patient relationship, relationships with
family, Mr. Stevens’ self-perception, and follow-through on treatment. So the moral intensity of the situ-
ation for Sophia is moderately high and requires more than consideration of her interests and desires or
those of society. Although Sophia needs to give considerable thought before acting, she is still left to make
a decision without much more guidance than consideration and prioritization of her ethical principles.
Practice-Based Model
Each of the models discussed so far is useful for guiding our understanding of ethical dilemmas and the
issues involved, but none addresses the fact that most dilemmas involve tension between two competing
“right” choices. Furthermore, none of the models is comprehensive enough to facilitate decision-making
across a number of different situations or contexts. Because legal mandates, professional guidelines, and
personal virtues provide only a modicum of direction when we are faced with an ethical dilemma, and
any decision we make can be and often is scrutinized and challenged, we need to develop a model for
ethical decision-making that is comprehensive, yet simple enough to allow a “standard for action” that we
can routinely follow.
• Immediacy of action
• Severity of impact
4. Act.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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30 Nursing Ethics in Everyday Practice
The practice-based model, developed from the work of Rushworth Kidder (1995), incorporates the key
aspects of the standards, principles, virtues, and moral reasoning-based approaches into a simple frame-
work based on the premise that most dilemmas are not moral issues of “right versus wrong,” but rather
“right versus right” dilemmas. In the dilemma confronted by Sophia, the practice-based approach would
suggest that she first ask whether or not the situation involves a moral issue. Though this might seem
rather superfluous, many dilemmas are primarily clinical or legal concerns rather than moral ones. For
example, maintaining confidentiality in the therapeutic setting is a clinical mandate. However, if I have
knowledge about child abuse or the potential for harm, I am legally mandated to break confidentiality and
report the information—regardless of any ethical or moral concerns. In the case of Sophia and Mr. Stevens,
the issue involves both ethical (for example, disclosure) and clinical concerns (compliance, treatment).
Having clarified the ethical concerns, I can now address the appropriate issues.
Practice-Based Model
1. Recognize the moral issue.
2. Determine the individuals involved.
3. Gather the relevant facts.
4. Test for right versus wrong issues.
5. Test for right versus right paradigms.
6. Determine resolution principles involved.
7. Investigate “trilemma.”
8. Weigh benefits & burdens.
9. Consult.
10. Consider dilemmas resulting from action.
11. Make the decision.
12. Formulate a justification for the decision.
13. Document.
14. Review & reflect.
From a moral reasoning or practice-based perspective, the next step would be consideration of the
moral intensity of the dilemma. Who are the individuals involved? How immediately is a decision need-
ed? What is the potential impact of this decision? As you might recall, we determined previously that So-
phia’s dilemma was moderately intense and, therefore, requires careful moral consideration. So, what are
the relevant facts? Mr. Stevens is depressed, not functioning well, withdrawn from family and friends, and
has passive suicidal thoughts. Sophia is the only person to whom this information is known. Sophia works
for the cardiologist who recently operated on Mr. Stevens. Mr. Stevens does not appreciate the severity of
his depression and has adamantly stated that he does not want his family informed.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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31Chapter 2: Ethical Decision-Making
Having identified the key players in the dilemma and the facts involved, we return to consideration of
the moral and ethical concerns. Is the issue of disclosure a “right versus wrong” decision, or is it a “right
versus right” dilemma? One quick test helpful in making this determination is what Kidder (1995) has
referred to as the “front page” test. Stated more fully, I ask, “Would I be comfortable having my decision
published on the front page of the paper?” Although some nurses might view disclosure as a clear-cut
“wrong” decision, most would agree that the issue of disclosing Mr. Stevens’ depression is not so straight-
forward and encompasses competing “right” choices. But what are the “right” choices?
As discussed earlier in the chapter, four basic paradigms underlie “right versus right” dilemmas and all
underscore the dilemma with Mr. Stevens. For example, Sophia wants to be truthful about Mr. Stevens’
situation but also feels loyal to him and respects his right to privacy. Although the decision about disclo-
sure primarily involves Mr. Stevens, Sophia must also consider the implications for Mr. Stevens’ family
and the cardiology practice. Mr. Stevens’ short-term needs are for improved functioning and self-care.
Equally important, however, are long-term goals of family support, health, and happiness. Finally, tension
exists between justice and mercy. Although Sophia wants to be just and fair in getting Mr. Stevens what-
ever care he needs, she also feels merciful toward him and wants to respect his wishes.
Having gained a better understanding about the “right versus right” nature of her dilemma, Sophia can
now reflect on the ethical principles she values and how these influence her thinking. Awareness of the
underlying principles can also help Sophia in her discussions with the cardiologist, who might disagree
with her about an appropriate action. From an ends-based approach, Sophia might decide to do whatever
is necessary to get Mr. Stevens the treatment he needs for his depression. However, notifying Mr. Stevens’
family against his will might not be a “rule” for action that Sophia would want adopted, and thus, she
might consider how she would want to be treated if in the same situation. If she values an individual’s
right to self-determination, Sophia would likely seek ways to support Mr. Stevens’ decision while also get-
ting him the care he needs.
Sophia now has a clear perspective on the dilemma, its ethical underpinnings, and the issues with
which she struggles in reaching a decision. At this point, she must consider a course for action. One of the
most useful aspects of Kidder’s approach to decision-making is the suggestion that, rather than focusing
on the two-choice “dilemma,” we instead focus on the “trilemma” in which multiple (at least three) pos-
sibilities for action are explored. Demanding that consideration be given to at least three options frees us
from the “either or” mentality and allows us to be creative in developing strategies for resolution.
For example, rather than Sophia deciding between disclosure or nondisclosure of Mr. Stevens’ depres-
sion to his family, she might decide to talk with Mr. Stevens about her concerns and educate him about
depression. She could also discuss various ways to help his worry that would be agreeable to him (for
example, increase his daily activity, encourage time with friends or family, arrange for him to attend a sup-
port group, give him referrals for therapy, consider medication). Sophia could also schedule an appoint-
ment for Mr. Stevens to talk with the cardiologist about his worries or arrange for him to meet with his
primary physician, if he has a good relationship there. As this example illustrates, encouraging exploration
of actions beyond the initial dilemma lessens the emotional intensity of the situation and fosters clearer
perspective. Some of the most complicated decisions I have faced have been resolved in the most satisfy-
ing way solely because I pushed myself to develop at least three ways for action.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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32 Nursing Ethics in Everyday Practice
Having several strategies for dealing with Mr. Stevens’ depression, Sophia must now make a decision.
How does she decide? As with any decision, the benefits and costs of each decision must be considered. If
Sophia decides to delay disclosure and arranges for Mr. Stevens to talk with his family doctor, how does
she know that he will follow through? What if nothing comes of the meeting? What is her obligation to
Mr. Stevens beyond the referral? In weighing the risks and benefits of any decision, I have found it ex-
tremely useful to consult with my colleagues. Not only does this give me fresh perspective on the situa-
tion, but in this age of unrestrained litigation, consultation allows the blame for any decision to be shared.
This might sound rather harsh, but sharing the burden for a decision can be reassuring, provide me with
professional support, and lend credence to my decision as a standard to which others agree (Hedges,
2007).
One last consideration before making the decision is to reflect on the potential consequences of the ac-
tion. More specifically, considering whether additional dilemmas might arise as a result of the decision is
often helpful. For example, Sophia does not know how Mr. Stevens’ family will respond if she decides to
contact them. What does she do if they are angry with Mr. Stevens for not notifying them sooner? What
if they are not interested? If she decides to refer him to his primary physician, what does she do if Mr.
Stevens does not keep the appointment? What if the physician doesn’t recognize the severity of his depres-
sion? Giving thought to potential outcomes allows us to recognize possible shortcomings of a decision
and to anticipate possible objections.
Reflective Practice
1. How would you prioritize the moral paradigms underlying Sophia’s dilemma?
2. What ethical principles would guide your decision-making?
3. What other ways could Sophia’s concerns about Mr. Stevens be addressed?
adapting the Practice-Based Model
Don’t let the number of steps in the model scare you. It is comprehensive but can be shortened
to quickly address whatever dilemma arises. You will also find that after only a few applications
of the model, the steps flow fairly naturally.
Having carefully considered all aspects of the dilemma, it is now time to make the decision. However,
our work is not yet done. Given that few mandates for action exist and most dilemmas are in ethical gray
areas, decisions such as these need to be documented and defended. By clearly articulating the steps taken
in reaching the decision, alternatives for action considered, justifications for the decision, limitations of
the decision, and consultations, the seriousness with which the action is considered is demonstrated. Such
behavior will not necessarily prevent legal or professional sanctions should others disagree with the deci-
sion. However, delineating the care taken in reaching a decision and having a set model by which we ap-
proach ethical dilemmas allow us to act in ways that are consistent with who we are and who we want to
become. Even without clear moral or legal guidelines for behavior, we can act in virtuous ways.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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33Chapter 2: Ethical Decision-Making
Finally, we need to review the decision-making process and reflect on the outcome of the decision after
the situation has resolved. What aspects of the situation were overlooked? Were there issues we failed to
consider? How could this be avoided in the future? Were we able to consider the situation objectively?
Are there ways the model could be altered to better aid our decision-making? Such reflection allows us
to develop an approach to decision-making that is malleable, relevant, and personal. For example, when I
am confronted with an ethical dilemma, all too often the emotion of the situation is so compelling, I fail
to take time to carefully think the situation through and instead quickly jump to a decision. Because of
this tendency, my own model of decision-making starts with the admonishment to “STOP. Take a deep
breath.” Only a few seconds of stepping away from the issue allows me to more carefully address the perti-
nent aspects of the situation and make an informed decision.
Conclusion
Throughout this chapter we have discussed the ethical challenges faced by nurses and how such dilemmas
can be resolved. Although a formal code of ethics delineates expectations for behavior, our personal
virtues and ideals are what enable us to act ethically. However, two ethically sound individuals may
disagree on a course of action precisely because their personal values differ. Reaching a decision about an
ethical situation is further complicated because typically there are at least two competing, equally right
choices rather than a right and wrong choice.
Ethical decision-making is particularly challenging in the field of psychiatry. Only in mental health
does society influence diagnostic decisions and ask us to make judgments about competence, right to
self-determination, and culpability. Thus, a framework for understanding and addressing mental health
dilemmas is imperative if we are to have a standard of care for consistent and effective resolution. Build-
ing on four major models of decision-making, the practice-based approach to ethical decision-making
incorporates the ethical principles of philosophy into the practical decision-making strategies of business.
Key elements of such a framework include identification and clarification of the issue, distinction between
a “right versus wrong” or “right versus right” dilemma, evaluation of the principles involved, creation of
a “trilemma,” weighing of benefits and burdens, consultation, and consideration of possible outcomes.
Following a decision, it is critically important that we document the steps we took in making the decision
and give time to review and reflect on the process.
I encourage you to use the principles, paradigms, and models discussed in this chapter to develop your
own framework for ethical decision-making. Not all of these will be applicable to you, your specialty, or
your work setting, but they can offer a foundation from which you can create a personal model for effec-
tively confronting and dealing with ethical dilemmas.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International.
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34 Nursing Ethics in Everyday Practice
Talk about It!
• Think about the last week you worked. What ethical situations did you face? Did any in-
volve “right vs. wrong” decisions or “right vs. right” dilemmas? What was the resolution?
How did you feel about the process and/or outcome? Share your explorations about
this situation with a colleague or your team. Discuss the different reactions each of you
had regarding the situation.
• Think about one particularly challenging ethical situation.
• Which ethical principles were involved?
• What were the competing moral paradigms?
• What courses of action were considered?
• How might it have helped to apply one of the models discussed in this chapter?
• In what ways would the models be less helpful?
• Explore this situation with someone in your life who is nonjudgemental but is
thoughtful of similar situations so that you can explore the situation with a “devil’s
advocate.”
• Discuss this same situation with a trusted colleague to explore the ethical principles he
or she values, what approach he or she would likely take, and what creative ideas for
resolution he or she offers. In what ways do you agree or disagree?
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ll
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rv
ed
.
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op
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2
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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
T
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is
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.
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lv
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?
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.
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fo
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ce
ss
in
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h
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re
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ce
s
2
.
G
at
h
er
in
fo
rm
at
io
n (c
on
tin
ue
d)
142
T
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(c
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)
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o
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m
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in
e
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e
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h
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is
su
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d
p
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le
s
6
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h
at
ar
e
th
e
co
n
fli
ct
s
b
et
w
ee
n
va
lu
es
o
r
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p
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n
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p
le
s?
7
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u
st
a
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is
io
n
b
e
m
ad
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an
d
,i
f
so
,
w
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.
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ti
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m
8
.
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av
ai
la
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?
9
.
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h
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et
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al
ju
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ti
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s
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iv
e?
1
0
.
W
h
at
ar
e
th
e
p
ro
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ab
le
o
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t-
co
m
es
o
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ch
al
te
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at
iv
e?
5
.
Li
st
in
g
th
e
al
te
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at
iv
es
6
.
Li
st
in
g
th
e
co
n
se
q
u
en
ce
s
4
.
Se
ek
a
re
so
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o
n
/
d
et
er
m
in
e
o
p
ti
o
n
6
.
R
ea
ch
re
so
lu
ti
o
n
4
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ta
te
yo
u
r
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ec
is
io
n
in
co
n
cr
et
e
te
rm
s
5
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u
st
ify
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e
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is
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n
7
.
T
h
e
ch
o
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e
8
.
Ju
st
ifi
ca
ti
o
n
5
.
W
o
rk
w
it
h
o
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er
s
to
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et
er
–
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in
e
a
co
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rs
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o
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ti
o
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eW
o
lf
B
o
se
k
(1
9
9
5
)1
5
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at
ti
so
n
(2
0
0
0
)1
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al
d
jia
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et
al
.
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0
0
5
)9
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au
m
an
n
-H
o
lz
le
et
al
.
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0
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)1
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R
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o
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se
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m
D
ec
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ys
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o
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en
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in
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ak
in
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h
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s
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th
ic
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lu
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lis
m
in
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–
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en
ti
al
is
m
&
d
eo
n
to
lo
gy
N
eo
n
at
al
in
te
n
si
ve
ca
re
u
n
it
C
o
lla
b
o
ra
ti
ve
d
ec
is
io
n
(C
o
n
se
q
u
en
ti
al
is
m
ap
p
ro
ac
h
)
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
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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
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Reply 1
1
Reply 1 2
explain the ethical and legal issues with
ONE (1) of the following topics:
·
· Genetic/genomic research
·
Respond:
· Take a position on the topic and include evidence to support your position.
Explain why your group agrees or disagrees with the stance and
provide citations or evidence to support it. Be constructive and professional in your responses. Remember to format in APA which avoids “I,” “we,” “you,” and similar pronouns. Recommend using terms like “the group” or “the nurses.”
Part II:
Summarize
and apply
the decision-making model you employed and the process used to arrive at your position.
Review the following resources from this week’s University Library Readings if you need additional information about ethical decision-making models:
· An Integrated Ethical Decision-Making Model for Nurses
·
Nursing Ethics in Everyday Practice: A Step-By-Step Guide, Ch. 2: Ethical Decision-Making
· 875-word paper
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