A Six-Step Process of Ethical Decision Making
Objectives
The reader should be able to:
• Identify six steps in the analysis of ethical problems encountered in everyday professional life and how each plays a part in arriving at a caring response.
• Describe the central role of narrative and virtue theories in gathering relevant information to achieve a caring response.
• Understand how the application of evidence based practice supports the ethical decision making process.
• List four areas of inquiry that will be useful when gathering relevant information to make sure you have the story straight.
• Describe the role of conduct-related ethical theories and approaches in arriving at a caring response.
• Describe why imagination is an essential aspect of seeking out the practical alternatives in an ethically challenging situation.
• Discuss how courage assists you in the ethical decision making procees.
• Identify two benefits of taking time to reflect on and evaluate a chosen moral action.
New terms and ideas you will encounter in this chapter
six-step process of ethical decision making
chemical restraints
evidence-based practice
time-limited trial
rounds
Topics in this chapter introduced in earlier chapters
| Topic | Introduced in chapter |
| Ethics | 1 |
| A caring response | 2, 3, 4 |
| Moral agency | 3 |
| Moral distress | 3 |
| Ethical dilemma | 3 |
| Ethical reasoning | 4 |
| The importance of story or narrative | 4 |
| Paternalism | 4 |
| Deontology | 4 |
| Utilitarianism | 4 |
| Character traits | 4 |
Introduction
You have come a long way in your search for resolution of ethical problems consistent with a caring response. Distinguishing prototypes of ethical problems and understanding ethical theories and approaches provides you with a necessary foundation to support your ethical reasoning. In this chapter, you have an opportunity to apply the conceptual tools you have learned using a problem-solving method to analyze and move toward resolution of ethical problems. The story of Michael Halloran and Amrou Croteau is a good starting point for this discussion.
The Story of Michael Halloran and Amrou Croteau
Amrou Croteau, a physical therapist, has just begun working in a municipal group home. The facility has a reputation for maintaining high standards of care. When Amrou interviewed for the position, she made a thorough tour of the home and talked with several employees and residents. Everything seemed “in order,” and she took the job.
Amrou is now ending her second week of work. She goes to the group home office to read the medical record of a resident who may be transferred to another facility because of his apparently worsening mental status. She learns that Mr. Michael Halloran is a 46-year-old man with cerebal palsy, insulin-dependent diabetes mellitus, renal hypertension, and a history of depression. Mr. Halloran has been a resident at the home for almost 2 weeks. He was admitted because of his inability to safely care for himself after a recent hospitalization for a fall and renal insufficiency. According to the record, he is “confused” most of the time and has required heavy sedation to “keep him from becoming violent.” Mr. Halloran is almost blind as a result of diabetic retinopathy. No neurologist’s report is found in the record.
Amrou decides to introduce herself to Mr. Halloran before she goes to lunch. When she finds Mr. Halloran’s room, she is surprised to see a frail-looking middle-aged man, slumped over in a wheelchair and struggling to read the sports section of the newspaper. Amrou introduces herself and tells Mr. Halloran that she is the physical therapist on staff and that she will be coming back to treat him in the afternoon.
Mr. Halloran squints in an effort to see Amrou. Abruptly he raises up on one elbow and says, “Maybe you’ll listen to me. I’m scared! They keep giving me shots and pills that make me crazy here! Can you get them to stop?”
Just at that moment, a nurse comes into the room with a syringe on a tray. “Hi, Mr. Halloran,” she says in a firm, loud voice. “Lift your johnny, please. It’s time for your shot!”
Mr. Halloran protests that the shots are making him “crazy as a hoot owl.” But the nurse has exposed his loose-skinned thigh and is deftly injecting the solution before Mr. Halloran succeeds in resisting. He tries to take a swipe at her, but she backs off quickly. She pats his bony hip and says, “There now, you’re okay, Mike,” and leaves immediately. Mr. Halloran leans back in the wheelchair and sighs. He looks toward Amrou and says, “See what I mean! I may have a disability, but I am not stupid. I know these places dope people like me so we stay quiet.” Amrou struggles with what to say to Mr. Halloran; he seems to be in genuine anguish. She reaches out to pat his hand, but he pulls it away, motioning her away with his paper.
Amrou is upset and confused. She has a gnawing feeling in her stomach that something is wrong in the way Mr. Halloran is being treated. At lunch, she shares her concern with Brenda Rendazzo, the nursing supervisor for the residence. Brenda is highly respected by residents and staff alike. Amrou tells Brenda it seems that Mr. Halloran is not being treated with the dignity that the residents deserve. She doubts that Mr. Halloran is “violent” but cannot put her finger on why she felt so much anger at the nurse who efficiently and without undue harshness gave him the injection. Maybe it is because she believes the medication is being used to “sedate” Mr. Halloran unnecessarily. As she recounts what happened, she can feel a seething rage rising up in her. She decides, on the spot, that she will talk to the group home administrator and announces that intention to Brenda.
Brenda listens attentively. When Amrou pauses for a few disinterested bites of her sandwich, she says, “Amrou, you have been here only 2 weeks. I can understand your uneasiness at what you thought you saw happening. And maybe you are right—maybe Mr. Halloran is not being treated with the respect he deserves. But remember, you are new here, and there is much that you don’t know. We are doing for him what we think is best, as well as trying to protect our staff from his dangerously aggressive behavior. He was worse before we started him on the benzodiazepines.”
Amrou does not feel any better after lunch. She wants to talk to someone and decides to call a colleague from graduate school who works as a social worker in another residential home.
As in most actual situations, Amrou’s first encounter with what appears to be an ethical problem has left many questions unanswered. The path from Amrou’s first perception to possible action consistent with a caring response traverses a six-step process of ethical decision making.
The Six-Step Process
Ethical decision making requires your thoughtful reflection and logical judgment (i.e., ethical reasoning, discussed in Chapter 4), although the situation usually presents itself in a “mumbo jumbo” of partial facts and strong reactions. The six-step process of ethical decision making provides a framework for working through ethical questions like the one Amrou is facing. The steps serve as practical tools to guide you through the intertwining of emotion, cognition, application, and action toward decision making. They allow you to take the situation apart and look at it in a more organized, coolheaded way while still acknowledging the intense emotions everyone may be experiencing about the situation and how these feelings factor into addressing the problem.
In Chapter 1, you learned that ethics is reflection on and analysis of morality. This step-by-step process is, overall, a formalized approach to both. In the context of healthcare, your professional ethics dictates that your reflection is directed toward arriving at a caring response in a particular situation. As a moral agent, your reflection and ensuing judgment are geared toward action.
Step One: Get the Story Straight—Gather Relevant Information
The first step in informed decision making is to gather as much information as possible. Anyone viewing this situation might ask the following questions:
• What clinical practice guidelines or research evidence support (or contradict) the use of benzodiazepines for clients with aggressive behavior?
• Does Mr. Halloran have cognitive changes from organic brain disease or other central nervous system dysfunction that might explain his agitation and aggressive behavior?
• What tests have been conducted to confirm the type and degree of neurologic involvement?
• What does his “violent” behavior consist of?
• Is he at risk of injuring himself or others?
• What might have happened in Mr. Halloran’s history to make him afraid of the nursing staff or the whole setting and therefore to react in a hostile manner?
• Has the medical director been made aware of Mr. Halloran’s complaints about the effects of the medication?
• What is the recent history of the exchanges between Mr. Halloran and the staff?
• What other approaches (besides medication) to Mr. Halloran’s ostensibly violent behavior have been, or could be, attempted?
• What resources/protections are in place for Mr. Halloran, given that he is a vulnerable client transitioning to residential care?
• What evidence is there that approaching the group home administration will create problems for Amrou, Ms. Rendazzo, or others?
• What other information about physical and chemical restraints (i.e., medicines that sedate the patient) in group residential settings should Amrou seek?
Reflection
Did you think of other questions as you read the story?
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The necessity for close attention to details takes you back to Chapter 4, which introduced the importance of the story or narrative. Without knowledge of as much as possible about the story, the attitudes, values, and duties embedded in it are impossible to ascertain. As you probably recall, the theories and approaches to ethics have important clues about how each of these is an important consideration if you will be able to arrive at a caring response. The fact-finding mission is absolutely essential as a safeguard against setting off on a false course from the beginning.
Some of the benefits of seeking out the facts in the situation described previously are that you may be able to determine whether Amrou’s perception of Mr. Halloran’s treatment is accurate and you may understand why the various players in this drama are acting as they are. Although Brenda Rendazzo’s comments are difficult to interpret, she may be implying that Amrou’s response would be tempered by more knowledge of the situation. Often, what initially appears to be a “wrong” act is, after all, a right or acceptable one once more of the story is known.
Fact finding also could help Amrou identify the focus of her anger more specifically. What triggered the response? Was it Mr. Halloran’s apparent helplessness in the situation? The nurse’s actions? What Amrou has read about the evidence surrounding the use and misuse of chemical restraints?1–3 Why has Mr. Halloran been labeled as “confused” and “violent” when Amrou believes he showed no signs of being either? Is Mr. Halloran’s assertion correct, that the staff are treating him differently because he is a disabled adult? Fact finding is an essential step in Amrou’s ethical reasoning process. She must clarify the known facts of the case versus the beliefs or stereotypes. All of the facts are needed to make a judicious and well-reasoned decision.
Attending to Evidence-Based Practice in Ethical Decision Making
Health professionals today are morally obligated to ensure their clinical decisions are informed and reflect best practice.4 Sound clinical reasoning integrates evidence-based practice with clinical expertise and the client’s preferences, beliefs, and values. Clinical research (reviews of data, metaanalyses, position papers) can lend substantial evidence to support ethical reasoning. Catlin puts this well when stating that “good ethics are based on good evidence.”5 Collecting all levels of evidence, from empirical studies to consultations with subject matter experts, is a key part of the gathering relevant information process to problem solve through step one of the ethical decision-making process.
The following general checklist for data gathering will help you organize your thoughts around your specific situation. The list is adapted from a handbook designed for clinicians.6
A. What is the diagnosis or prognosis?
B. Is the illness or condition reversible?
C. What are the patient’s symptoms?
D. What is the present treatment regimen?
E. What evidence supports this treatment regime? Does any evidence contradict it?
F. What is the usual and customary treatment for this type of condition?
G. What is needed to relieve suffering or to provide comfort?
H. Who are the primary caregivers?
I. What can you learn about this patient’s medical and social history?
J. Who are the members of the interprofessional care team that is treating this patient, and what are the results of their evaluations and treatments to date?
2. Preference of the Patient
A. What outcome does the patient want in this situation?
B. Who has communicated the realistic options to the patient?
C. What was the patient actually told?
D. What evidence do you have that the patient’s needs, wants, and fears have been heard by key decision makers?
E. Is the patient competent to make decisions about this situation?
F. Do any family or other cultural influences need to be taken into account? If the patient is not competent, is another person speaking as a legitimate legal substitute for the patient?
3. Quality of Life
A. What are the patient’s beliefs and values that make up his or her personal value system?
B. What quality-of-life considerations are professional and family caregivers bringing to this situation, and how are their biases influencing the decision processes?
C. Is there any hope for improvement in the patient’s quality of life?
D. Are there any biases that might prejudice the interprofessional care team’s evaluation of the patient’s quality of life?
4. Contextual Factors
A. What institutional policies may influence what can be done?
B. What are the legal implications (court cases, statutes, and so on) regarding this issue?
C. Are scarce resources an issue?
D. How will these services be paid?
E. Are there family caregiver issues that may influence the plan of care?
Reflection
This general checklist is extensive but not exhaustive. Jot down some other types of information you think will help Amrou to accurately analyze this situation.
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Summary
Gathering as much relevant information as possible sets the essential groundwork for analysis and action consistent with arriving at a caring response.
When you have searched out the information you and others deem relevant or when you are convinced no additional helpful information is forthcoming, you are ready to proceed to the next step.
Step Two: Identify the Type of Ethical Problem
Even while the initial fact finding is taking place, Amrou can begin to determine the type of ethical problem (or problems) she is facing and in that regard make significant progress toward arriving at a caring response. In the beginning, her worry was the following.
Mr. Halloran is a human, and the gold standard of care (as introduced in Chapter 1) is that humans always should be treated with dignity. Part of being treated with dignity includes patients taking part in their own treatment decisions whenever possible; in Mr. Halloran’s case, this includes, at the very least, being treated with sensitivity to the anguish that he appears to be experiencing. To ignore his distress shows a lack of compassion, if not outright cruelty, and reduces him to the status of an object. Mr. Halloran is not being treated as a person ought to be treated, which blocks the goal of achieving a professional caring response.
This is where the prototypes of ethical problems you encountered in Chapter 3 begin to work for you.
Moral Distress
You know that Amrou is experiencing emotional distress. She has witnessed a scene that baffled her, and she finds herself unable to forget about it. Our guess about the fundamental basis of Amrou’s distress is her perception that Mr. Halloran is not being treated with the dignity he deserves as a human. The distress, then, is consistent with Amrou’s role as a professional with a moral responsibility to help uphold human dignity. In other words, she is a moral agent in a situation that she surmises involves morality, and that, because it is worrying her, merits further attention. If she tries, but fails, to put more information in place, she may confirm that her distress is, in fact, moral distress type B. You also can presume that she has the virtues of a compassionate person, otherwise she would not be worried about what she witnessed.
Ethical Dilemma
Goaded by her emotional responses, character traits, and the awareness that she is experiencing moral distress, Amrou is well positioned to assess whether she also has an ethical dilemma (or dilemmas). Do you think there is an ethical dilemma here?
Amrou learns that quite a few of the staff (but not all) believe the medications are being used disproportionately to the amount of “violence” Mr. Halloran has been demonstrating. In fact, some of the staff confide that they believe he is being sedated not to benefit him but to keep him more in line with the conduct of the other more docile and cooperative residents. Mr. Halloran has seemed very agitated and suspicious at times, and the medication has helped to improve his feeling of security, so that raises the possibility that it is benefiting him in that way. Of course, the group home is shorthanded, and the administrator points this out when Amrou finally goes to talk with her. Her argument is that if everyone took as much time and extra attention as Mr. Halloran did (when not medicated), no one would receive a fair amount of treatment. The principle of justice introduced in Chapter 4, and addressed more thoroughly in Chapter 14, is an issue.
Finally, the administrator mentions that some of the staff are afraid of Mr. Halloran and that she has a responsibility for their safety too. There are several issues here in which Amrou, as an employee and interprofessional team member, may be implicated as partial agent. Foremost of these is whether the employees, as a team, are acting ethically in the use of restraints under any circumstances. The one ethical dilemma that falls squarely on Amrou’s shoulders at the moment, however, is this: Amrou’s dilemma arises from the fact that she has become more persuaded that she was right about what she saw happening to Mr. Halloran. She believes the principle of beneficence to him is being compromised. But she can also agree with the points made by the administration and some of the staff regarding fairness to other residents. She is experiencing difficulty in deciding what to do to honor the several principles that guide professional action in this situation. In summary, she has an ethical dilemma.
Moral Agency
If Amrou decides that someone other than herself, the administration, or the other team members should be making decisions regarding any aspects of Mr. Halloran’s treatment (or the group home policies regarding treatment), she may face a locus of authority conflict. For instance, although the story does not give you the benefit of knowing whether Mr. Halloran’s input is being included in the decision, Amrou could decide that the authority for this decision should rest with Mr. Halloran. From what we have been told, we can assume that the staff and medical director have determined that the patient is not competent to make such a decision and therefore they are acting paternalistically. Regardless, it is important to remember that all members of the interprofessional care team share agency in ensuring that Mr. Halloran recieves the care he deserves. They must work together, with the patient and the administration, to navigate conflict and execute a safe, efficient, and effective plan of care.
Summary
An essential step in analysis is to identify the type or types of ethical problems that you face.
Step Three: Use Ethics Theories or Approaches to Analyze the Problem
In Chapter 4, you were introduced to ethical theories and approaches. You have seen in the preceding pages that the narrative approach, which keeps relevant details of the story at the center of Amrou’s deliberation, is the most crucial for her eventual decision to be consistent with professional ethics. She also needs certain basic attitudes to help guide her on the path of a caring response as she deals with her own anger about what she observes. Therefore, virtues such as compassion are among her most fundamental resources. You learned that situations that require the health professional to be an agent (i.e., take action for which she or he is morally accountable) draw on ethical theories that focus on principles, duties and rights, and/or consequences. In other words, they are the tools for action.
Take a minute to review these action theories:
Focuses on the overall consequences
2. Deontology
Amrou’s story may make comparison of the two theories easier than when they were presented in Chapter 4.
If agent (A), Amrou, is like most health professionals and is guided by the principles of duty and rights in her professional role, she probably will decide that her weightier (i.e., more compelling) responsibility is to Mr. Halloran.
If agent (A), Amrou, approaches the dilemma from a utilitarian standpoint, she will spend less time thinking about duties to Mr. Halloran and will be guided by the desire to bring about the overall best consequences in this situation. The overall best consequences may be to “leave well enough alone” and ensure the safety of the other residents and her coworkers.
Reflection
Which approach do you find yourself leaning toward in Amrou’s and Mr. Halloran’s situation? Why?
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Recall the ethical principles you learned in Chapter 4. Which principles can be balanced when considering the use of chemical restraints for Mr. Halloran?
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Summary
In step three, you use ethical theories and approaches as the foundation for your ethical reasoning, which moves you toward resolution and action that is consistent with a caring response.
Step Four: Explore the Practical Alternatives
Amrou has decided what she should do. The next step is to determine what she can do in this situation. She must exercise her ingenuity and confer with her colleagues regarding the actual strategies and options available to her. Suppose she decides that her initial perceptions were correct and that she must act on behalf of Mr. Halloran, even though the staff sees no problem?
At this juncture, many people oversimplify the range of options available. They tend to fall back on old alternatives when under stress, a behavioral pattern you can probably recognize from your own stressful situations. Therefore, imaginative pursuit of options is a big challenge, but an invaluable resource, in resolving ethical problems. In recounting Amrou’s story, we learned that she believed her range of options was to confront the group home administrator or do nothing. A diligent search for other options can now make the difference between her doing the right thing or allowing a moral wrong to go unchecked.
Reflection
Apply your own thinking to Amrou’s situation and list all the alternatives you believe she has. Try to identify a minimum of four.
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3. _____________________________________________________________
4. _____________________________________________________________
After listing the alternatives, which one do you think is the best? Why?
Often, a good idea is to try out some of the more far-fetched alternatives with a colleague whom you trust and with whom you can share the situation without breaching the patient’s confidentiality. Amrou did this with the nursing supervisor. We do not know how the supervisor’s counsel helped in the end, but we are sure that her words led Amrou to further examination of what her next step should be.
It is also important not to limit your range of alternatives based on time. In some situations, an alternative is proposed as a time-limited trial. This allows the provider or interprofessional care team the opportunity to both negotiate and think innovatively about solutions that support a caring response. A time-limited trial must be aligned with the patient’s goals of care and be weighed for its benefits and burdens. Time-limited trials are further discussed in Chapters 12 and 13, when we explore ethical dimensions in chronic and end-of-life care.
Summary
Imagination enhances ethical decision making by allowing you to think more creatively and expansively about the alternatives.
Step Five: Complete the Action
Think of all the work Amrou has already done. She responded to her initial feeling that something was wrong; followed her compassionate disposition that motivated her not to let the matter go unnoticed; thought about and decided on the type of ethical problem(s) she was encountering; applied one or more ethical theories and approaches to support her reasoning; and exercised her imagination to identify practical options needed to effect a caring response. She also shared her worry with at least one other person she knew commands her respect and that of others. Now she has one more task, but it is the crucial one, and that is to act.
If Amrou fails to go ahead and act, the entire process so far is reduced to the level of an interesting but inconsequential philosophic exercise; worse, it may result in harm to Mr. Halloran. Of course, Amrou may consciously decide not to pursue the situation any further, but insofar as it involved her deliberate intent, it is different than simply failing to follow what seems a correct course of action. If harm comes to Mr. Halloran or others because of Amrou’s inaction or unnecessarily narrow focus, she is an agent of harm by her own omission or neglect. The solid ethical foundation she laid in steps one to four will have been of no avail.
Why would anyone fail to act in this type of circumstance? Mainly because it is sobering to be an agent in such important matters of meaning and value in others’ lives.
Summary
The goal of your analysis is finally to act!
Some decisions are literally life-and-death decisions, but all are of deep significance to the people who face the particular situation. Although the previous step required imagination, this final step requires courage and the strength of will to go ahead, with the knowledge that there may be risks or backlashes. As Amrou becomes more experienced, she will be increasingly aware that her integrity of purpose must be supported by her sound ethical reasoning, compassion, and courage.
Step Six: Evaluate the Process and Outcome
Once she has acted, it behooves Amrou to pause and engage in a reflective examination of the situation. The practical goal of ethics is to resolve ethical problems, thereby upholding important moral values and duties. The extent to which Amrou’s decision led to action that upheld morality, however, is knowable only by reexamining what happened in the actual situation. This evaluation is germane to her growth and development as an ethical professional and is essential if the outcome she hoped for was not realized.
In the traditional medical model, a widespread mechanism for addressing interventions that go awry in the clinical setting is morbidity and mortality (“m and m”) rounds. If you have not yet been in the clinical setting, the term “rounds” may be new to you. Rounds is the general term used for meetings of clinicians. Some rounds are held sitting in a room (sit-down rounds), and others are held walking from patient to patient (walking rounds). Morbidity and mortality rounds allow health professionals whose interventions did not yield the hoped-for results to present the case to their peers for further evaluation. Sometimes ethical committees or your own unit staff meetings conduct ethics morbidity and mortality rounds to have a group review of a particularly difficult situation that seemed not to meet the ethical goal of a caring response. Rounds are a means for reflective discernment. They are an explicit way for the interprofessional care team to reflect on practice. This type of activity promotes ethical reasoning, supports interprofessional communication, and helps ensure that care is individualized, just, and benevolent.7,8
Amrou’s case is not unique. Studies have shown that the topics of conflict around goal setting and dual obligations are among the most frequently cited ethical issues encountered by rehabilitation practitioners.9–12 Given this, suppose you, like Amrou, have just been through the process of arriving at a difficult ethical decision and have acted on it. Some questions you might ask yourself are the following:
• What were the most challenging aspects of this situation?
• How did this situation compare with others you have encountered or read about?
• To what other kinds of situations will your experience with this one apply?
• Who was the most help?
• What do the patient, family, and/or others have to say about your course of action?
• Overall, what did you learn?
• Do you think in retrospect that you failed to give adequate attention to anything?
• Did you miss the mark at one or more times? In what regard?
• What would you do differently if you were faced with the same situation again?
All of these will serve you well in your preparation for the next opportunity to decide what a caring response entails in that new situation. When you reflect, you advance your ethical reasoning and are better prepared for the next time you are faced with a challenging situation (Figure 5-1).
Summary
Reflection is the link to critical thinking. It allows you to reframe problems, extract meaning from experiences, and engage in lifelong learning to bring about best practice in a variety of settings.
Summary
If you studied this chapter carefully, you have identified the six-step process that anyone faced with an ethical question can apply in searching for a caring response.
Gather as much relevant information as possible to get the facts straight.
2. Identify the Type of Ethical Problem
If step one confirms that there is one.
3. Use Ethics Theories or Approaches to Analyze the Problem
Decide on the ethics approach that will best get at the heart of the problem identified in step two.
4. Explore the Practical Alternatives
Decide what should be done and how it best can be done (explore the widest range of options possible).
5. Complete the Action.
Call upon your strength of will and moral courage to act.
6. Evaluate the Process and Outcome
Reflect on your experience to better prepare yourself for future situations.
Questions for Thought and Discussion
1. The first step in ethical decision making is to gather as much relevant information as possible. The information-gathering process, however, can become so extensive that it could become an end in itself and could actually deter one from proceeding to action at all. What types of guidelines would you use to decide that you have as much information as you need or can obtain?
2. A necessary step in ethical decision making is to act on one’s own conclusions about what ought to be done. Under what conditions, if any, would you decide not to act according to your own best moral insights and judgment? That is, what, if any, are the limits to your willingness to act ethically?
3. In your professional career, you would much prefer always to act ethically. What type of reflective practices will you integrate into your work life to ensure that you think critically about both the art and science of your patient care delivery? Who has served as a resource to you in the past to help you advance your thinking and level of reflection? Will that person continue to help you evaluate your decision-making process? If not, what structure will you need to ensure that you continually improve your practice through the reflective cycle?