Ethical Decision Making
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Introduction
Just as nursing applies a
systematic process for evaluating the condition of a given population to
determine an appropriate intervention, health care providers must also utilize
a systematic process to assess the nature of an ethical dilemma to determine a
reasonable solution.
Ethical decisions are
reasoned choices based on:
· The dilemma itself.
· The principles in conflict.
· The people involved.
· The outcome of the proposed action.
· The ethical reasoning process selected.
Ethical Decision Making
It is helpful to use a
decision-making model for ethical dilemmas in order to guide one's decision
making from an objective, cognitive perspective, rather than a purely affective
or emotional perspective. Uustal (1993) proposed the following steps to guide
one's ethical decision making. Uustal's model not only follows the nursing
process, but also includes values clarification when applying an ethical
decision-making model.
Step 1: Identify the problem.
Ask:
· Who are people involved in the dilemma?
· How are they related or interrelated?
· What is involved in the situation?
After answering the above
questions, identify the ethical dilemma and make a concise statement of the
problem. Then, state the conflict in values.
Step 2: State your values and ethical position related to the problem.
· How does the issue fit with your personal values?
· Are they congruent or incongruent?
Step 3: Take into consideration
factors that relate to the situation and generate alternatives for resolving
the dilemma.
Step 4: Examine and
categorize the alternatives. Identify those that are consistent and
inconsistent with your personal values.
If the most appropriate
alternative is inconsistent with your personal values, another provider may be
needed to facilitate resolution. This eliminates bias and preserves your own
ethical integrity.
Step 5: Predict all possible
outcomes for those acceptable alternatives.
Consider physical,
psychological, social, and spiritual consequences, both short-term and
long-term.
· What might happen if you follow Alternative A?
· What might happen if you follow Alternative B?
Step 6: Prioritize acceptable
alternatives. List them in order from the most acceptable to the least
acceptable.
Step 7: Develop a plan of
action utilizing the list of acceptable alternatives. Determine what you are
going to do about this dilemma.
Step 8: Implement the plan.
Step 9: Evaluate the action
taken. Ask yourself the following questions:
· Did I do the right thing?
· Were my actions ethical?
Characteristics of Ethical Dilemmas
Following is a review of
the characteristics of ethical dilemmas:
· The choice is between equally undesirable alternatives.
· Real choice exists between possible courses of action.
· The people involved in the dilemma place a significantly different
value judgment on possible actions or on the consequences of actions.
That is why there is a conflict. If everyone involved agreed, there would be no
ethical dilemma.
· Data alone will not help
resolve the dilemma. One always wants more data, but it is not
available.
· Answers to the ethical
dilemma come from a variety of disciplines (e.g., psychology,
sociology, theology).
· Actions taken in an ethical dilemma will result in unfavorable
outcomes and/or constitute a breach of one's duty to another person.
Although the action taken may meet the needs of one person or party, it may
result at the expense of another.
· The choices made in an ethical dilemma have far-reaching
effects on our perception of human beings and definition of
personhood, our relationships, and people in society as a whole.
· Any ethical decision involves the allocation and expenditure
of resources which are finite. If there were an infinite
amount of resources to share with everyone in need, there would be no dilemma
in deciding who gets the scarce resource.
· Ethical dilemmas are not solvable, but
rather resolvable. A solution would mean that the problem is fixed.
A resolution means that a decision has been made to determine a course of
action in the situation.
When one is faced with an ethical dilemma, there are specific
ethical questions to address:
· What ought to be done in this case?
· Who should be involved in the decision making process?
· Who has the right to make the final decision? Why?
· For whom should the decision be made: for oneself, someone for
whom you are acting as a proxy, or others?
· What criteria should be used in a dilemma? Psychological
condition only? Physiological status, economic concerns, legal factors, social
and family perspectives, or spiritual considerations?
· What degree of consent should be obtained from the client?
· What harm or benefits will result from the decision and
resulting actions?
· Does the ability to intervene justify the intent to do so? Just
because it is possible, does it make it right?
Ethics Committees
As a response to the
growing number of ethical questions stemming from scientific advancement,
President George Bush established a President's Council on Bioethics in January
of 2002. A significant step to approaching ethical dilemmas was made when the council
mandated the creation of ethics committees in acute care settings. These
committees are comprised of members from different disciplines in and outside
of health care as well as laypersons from the community. Committees often
include an ethicist (educated in ethical consultation), a lawyer, a quality
improvement manager, a physician, a nurse, a clergyman or other spiritual
director, and an individual from the community at large.
In the coming together of
differing experiences, educational backgrounds and unique perspectives, the
committee as a whole can produce a well-balanced discussion of alternatives. In
addition, these committees can provide recommendations intended to advocate for
patient's rights and promote shared decision making, even in the face of the
most challenging of ethical dilemmas. While the alternatives and
recommendations offered by an ethics committee do not have the weight of law,
they make a significant influence on decision making at the bedside and have
the power to influence a judge or jury during any deliberation involving
patient rights.
Conclusion
As long as the delivery
of health care involves human life, changing technology, and finite resources,
health care professionals will face ethical dilemmas on a daily basis. Often
times, life-changing decisions must be made quickly. Because of the long-term
and life-altering effects of many actions, it is important that ethical
dilemmas be resolved in accordance with ethical principles and theories. Just
as health care professionals practice CPR in order to be able to perform it
efficiently in a real situation, it is important that health care professionals
practice ethical decision making in a classroom setting so that they are in
tune with their own values and are better prepared to make ethical decisions
when they occur in the clinical setting.
References
Uustal. D. B. (1993). Clinical ethics & values:
Issues and insights. East Greenwich, RI: Educational Resources in
Healthcare.
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