A. The RESOLVEDD Method by Jonathan L.

Kvanig
1. R Review the facts Review history, background and details of case o What are the details? o What is the background? 2. E Estimate (specify) the conflict or problem present in the case, i.e., what is at issue or at stake. 3. S ist main possible solutions to the case. 4. O !tate important and probable outcomes or conse"uences of each solution. o What will happen? o What is likely to happen? o What might happen? 5.L #escribe likely impact of each main solution on people$s lives, and on the interests and concerns of entities (i.e., institutions, organi%ations, companies, governments and states), as well as nonhumans and the environment. o Who will be benefited? o Who will be harmed? o Who else will be impacted and how? . V E&plain the values upheld and those infringed by each main solution. o Refer to relevant moral principles' honesty, harm, fidelity, autonomy, confidentiality, lawfulness, e"ual consideration of interests( o )haracteri%e salient moral rights' knowledge, privacy, life, free e&pression, due process, safety, property, profitability( o *nclude the consideration of the interests and rights of future generations. !. E Evaluate each main solution in terms of outcomes, likely impact and values upheld or infringed. ". D #ecide which solution is best, state it, clarify its details, and +ustify it. #. D #efend the decision against ob+ections to its main weaknesses.

$. 12 %&e'tion'( by La&)a *a'h

,. -ave you defined the problem accurately? .. -ow would you define the problem if you stood on the other side of the fence? /. -ow did this situation occur in the first place? 0. 1o whom and what do you give your loyalties as a person and as a member of the 2institution3? 4. What is your intention in making this decision? 5. -ow does this intention compare with the likely results? 6. Whom could your decision or action in+ure? 7. )an you engage the affected parties in a discussion of the problem before you make your decision? 8. 9re you confident that your position will be as valid over a long period of time as it seems now? ,:. )ould you disclose without "ualms your decision or action to your boss, your )E;, the board of directors, your family, or society as a whole? ,,. What is the symbolic potential of your action if understood? *f misunderstood? ,.. <nder what conditions would you allow e&ceptions to your stand?

+. A ,o)-at .o) Ethi/a0 De/i'ion Ma1ing by Mi/hae0 Davi'

,. !tate problem (e.g. =#o * have a conflict of interest?> or even =1his makes me uncomfortable>) .. )heck facts (some problems disappear upon closer e&amination of situation( others change radically). /. !tate specifications (limits and ob+ectives)?laws, professional code, and corporate rules to be satisfied, cost constraints (e.g. under @.::), children to feed, place in life plan (e.g. save company). 0. #evelop list of at least five options (be imaginative, try to avoid =dilemma>?not =yes> or =no> but who to go to, what to say). 4. 1est options, using such tests as the following' A -arm test?does this option do less harm than any alternative? A Bublicity test?would * want my choice of this option published in the newspaper? A #efensibility test?could * defend my choice of this option before a )ongressional committee, a committee of my peers, or my parents? A Reversibility test?would * still think the choice of this option good if * were one of those adversely affected by it?

A Cirtue test?what would * become if * choose this option often? A Brofessional test?what might my professionDs ethics committee say about this option? A )olleague test?what do my colleagues say when * describe my problem and suggest this option as my solution? A ;rgani%ation test?what does the organi%ationDs ethics officer or legal counsel say about this? 5. Eake a tentative choice based on steps ,F4. #id you solve the problem with which you began? 6. Eake final choice (after reviewing steps ,F5), act, and then ask' What could make it less likely you would have to make such a decision again?

A What precautions can you take as individual (announce policy on "uestion, change +ob, etc.)? A What can you do to have more support ne&t time (e.g., seek future allies on this issue)? A What can you do to change organi%ation (e.g., suggest policy change at ne&t dept. meeting)? A What can you do to change larger society (e.g. work for new statute or EB9 regulation)?

D. A ,)a-e2o)1 .o) Ethi/a0 De/i'ion3Ma1ing4

1. +o00e/t in.o)-ation and identi.y the 5)ob0e-. 1.1. $e a0e)t6 be 'en'itive to -o)a00y /ha)ged 'it&ation' ook behind the technical re"uirements of your +ob to see the moral dimensions. <se your ethical resources to determine relevant moral standards 2see Bart ***3. <se your moral intuition. 1.2. 7denti.y 2hat yo& 1no2 and don8t 1no2 While you gather information, be open to alternative interpretations of events. !o within bounds of patient and institutional confidentiality, make sure that you have the perspectives of patients and families as well as health care providers and administrators. While accuracy and thoroughness are important, there can be a tradeFoff between gathering more information and letting morally significant options disappear. !o decisions may have to be made before the full story is known.

1.3. State the /a'e b)ie.0y 2ith a' -any o. the )e0evant .a/t' and /i)/&-'tan/e' a' yo& /an gathe) 2ithin the de/i'ion ti-e avai0ab0e A What decisions have to be made? A Who are the decisionFmakers? Remember that there may be more than one decisionmaker and that their interactions can be important. A Ge alert to actual or potential conflict of interest situations. 9 conflict of interest is Ha situation in which a person, such as a public official, an employee, or a professional, has a private or personal interest sufficient to appear to a reasonable person to influence the ob+ective e&ercise of his or her official dutiesH. 1hese include financial and financial conflicts of interest (e.g., favouritism to a friend or relative). *n some situations, it is sufficient to make known to all parties that you are in a conflict of interest situation. *n other cases, it is essential to step out 2of3 a decisionFmakin role.2/3 1.4. +on'ide) the /onte9t o. de/i'ion3-a1ing 9sk yourself why this decision is being made in this conte&t at this time? 9re there better conte&ts for making this decision? 9re the right decisionFmakers included? )onsider the following "uestions' +0ini/a0 7''&e' A What is the patient$s medical historyI diagnosisI prognosis? A *s the problem acute? chronic? critical? emergent? reversible? A What are the goals of treatment? A What are the probabilities of success? A What are the plans in case of therapeutic failure? A *n sum, how can the patient be benefited by medical, nursing, or other care, and harm avoided? :)e.e)en/e' A What has the patient e&pressed about preferences for treatment? A -as the patient been informed of benefits and risks( understood, and given consent? A *s the patient mentally capable and legally competent? What is evidence of incapacity? A -as the patient e&pressed prior preferences, e.g., 9dvanced #irectives? A *f incapacitated, who is the appropriate surrogate? *s the surrogate using appropriate standards? A *s the patient unwilling or unable to cooperate with treatment? *f so, why? A *n sum, is the patient$s right to choose being respected to the e&tent possible in ethics and law?

%&a0ity o. Li.e;Death A What are the prospects, with or without treatment, for a return to the patient$s normal life? A 9re there biases that might pre+udice the provider$s evaluation of the patient$s "uality of life? A What physical, mental, and social deficits is the patient likely to e&perience if treatment succeeds? A *s the patient$s present or future condition such that continued life might be +udged undesirable by himIher? A 9re there any plans and rationale to forego treatment? A What are the plans for comfort and palliative care? +onte9t&a0 ,eat&)e' A What chapter is this in the patient$s life? A 9re there familyIcultural issues that might influence treatment decisions? A 9re there provider (e.g. physicians and nurses) issues that might influence treatment decisions? A 9re there religious, cultural factors? A *s there any +ustification to breach confidentiality? A 9re there problems of allocation of resources? A What are the legal implications of treatment decisions? A *s there an influence of clinical research or teaching *nvolved? .. !pecify feasible alternatives. !tate the live options at each stage of decisionFmaking for each decisionFmaker. Jou then should ask what the likely conse"uences are of various decisions. -ere, you should remember to take into account good or bad conse"uences not +ust for yourself, your profession, organisation or patients, but for all affected persons. Ge honest about your own stake in particular outcomes and encourage others to do the same. 3. <'e yo&) ethi/a0 )e'o&)/e' to identi.y -o)a00y 'igni.i/ant .a/to)' in ea/h a0te)native. 3.1. :)in/i50e' 1hese are principles that are widely accepted in one form or another in the common moralities of many communities and organi%ations. A 9utonomy' Would we be e&ploiting others, treating them paternalistically, or otherwise affecting them without their free and informed consent? -ave promises been made? A KonFmaleficence' Will this harm patients, caregivers, or members of the general public? A Geneficence' *s this an occasion to do good to 2or for3 others? Remember that we can do good by preventing or removing harms.

A Lustice' 9re we treating others fairly? #o we have fair procedures? 9re we producing +ust outcomes? 9re we respecting morally significant rights and entitlements? A Midelity' 9re we being faithful to institutional and professional roles? 9re we living up to the trust relationships that we have with others. 3.2. Mo)a0 -ode0' !ometimes you will get moral insight from modelling your behaviour on a person of great moral integrity. 3.3. <'e ethi/a00y in.o)-ed 'o&)/e' Bolicies and other source materials, professional norms such as institutional policies, legal precedents, and wisdom from your religious or cultural traditions. 3.4. +onte9t )onte&tual features of the case that seem important such as the past history of relationships with various parties. 3.5. :e)'ona0 =&dg-ent' Jour +udgments, your associates, and trusted friends or advisors can be invaluable. ;f course in talking a tough decision over with others you have to respect client and employer confidentiality. #iscussion with others is particularly important when other decisionFmakers are involved, such as, your employer, coF workers, clients, or partners. Jour professional or health care association may provide confidential advice. E&perienced coFworkers can be helpful. Eany forwardFlooking health care institutions or employers have ethics committees or ombudsmen to provide advice. #iscussion with a good friend or advisor can also help you by listening and offering their good advice. 3. O)gani>ed 5)o/ed&)e' .o) ethi/a0 /on'&0tation )onsider a formal case conference(s), an ethics committee, or an ethics consultant. 4. :)o5o'e and te't 5o''ib0e )e'o0&tion'. 4.1. ,ind the be't /on'e?&en/e' ove)a00 Bropose a resolution or select the best alternative(s), all things considered. 4.2. :e).o)- a 'en'itivity ana0y'i' )onsider your choice critically' which factors would have to change to get you to alter your decision? 1hese factors are ethically pivotal. 4.2. +on'ide) the i-5a/t on the ethi/a0 5e).o)-an/e o. othe)' 1hink about the effect of each choice upon the choices of other responsible parties. 9re you making it easier or harder for them to do the right thing? 9re you setting a good e&ample?

4.3. @o&0d a good 5e)'on do thi'A 9sk yourself what would a virtuous person N one with integrity and e&perience N do in these circumstances? 4.4. @hat i. eve)yone in the'e /i)/&-'tan/e' did thi'A Mormulate your choice as a general ma&im for all similar cases? 4.5. @i00 thi' -aintain t)&'t )e0ation'hi5' 2ith othe)'A *f others are in my care or otherwise dependent on me, it is important that * continue to deserve their trust. 4. . Doe' it 'ti00 'ee- )ightA 9re you and the other decisionFmakers still comfortable with your choice(s)? *f you do not have consensus, revisit the process. Remember that you are not aiming at =the> perfect choice, but a reasonably good choice under the circumstances. 5. Ma1e yo&) /hoi/e. 5.1. Live 2ith it 5.2. Lea)n .)o- it 1his means accepting responsibility for your choice. *t also means accepting the possibility that you might be wrong or that you will make a less than optimal decision. 1he ob+ect is to make a good choice with the information available, not to make a perfect choice. earn from your failures and successes. Bostscript' 1his framework is to be used as a guide, rather than a =recipe>. Ethical decisionFmaking is a process, best done in a caring and compassionate environment. *t will take time, and may re"uire more than one meeting with patient, family, and team members.

The Seven Ste5 Method .o) Ana0y>ing Ethi/a0 Sit&ation'

9nother tool for analy%ing ethical situations is to follow the !even !tep Eethod for deciding what action to take in a situation. 1he method involves answering seven =what> "uestions' ,. 1he Macts? .. 1he Ethical *ssues?

/. 1he 9lternatives? 0. 1he !takeholders? 4. 1he Ethics of the 9lternatives? 5. 1he Bractical )onstraints? 6. 9ctions to 1ake? ;ne reason for using the seven step method is to provide a mental checklist to insure completeness in making the ethical analysis. 9 person making an ethical decision needs a procedure to follow to insure that she makes her decision with rationality and respectFFa decision procedure that can insure that she has considered all the relevant factors and have taken into account the interests of others as well as herself. Celas"ue% has developed a seven step method for this purpose. Eost decision makers, when confronted with an ethical decision, would consider most of the relevant factors. 1he seven step method provides a mental checklist to insure that the essential factors are included. 1he method also provides a framework for locating difficulties and disagreements.Gy separating facts from ethical issues, for e&ample, the framework allows us to determine whether a disagreement is over the facts or over the ethical issues. *n discussing a social policy to control violence with firearms, for e&ample, the "uestion of whether cheap handguns are used in a significant percentage of violent incidents is a factual "uestion. 1he "uestion of whether <.!. citi%ens have a right to bear arms and whether the society has a legitimate claim to limit that right are ethical issues. Mactual "uestions and ethical issues re"uire a different kind of investigative process to produce answers so it is important to be clear as to which kind of "uestion we are asking. Ethical decision making is a dialectical process. 1he fact that the seven steps are listed in numerical order does not indicate a strict logical or chronological order. 1he presence of certain facts will alert us to the need to consider certain ethical issues, but without some prior ac"uaintance of the ethical issues, these facts would not have any ethical 'igni.i/an/e. #etermining what the alternatives are, who the stakeholders are, or what the practical constraints are may send us in search of additional facts. )onsidering who the stakeholders are maygenerate new alternatives. 1he insight generating capacity of the ethical principles used to determine the ethics of the alternatives may raise new ethical issues or point us toward additional stakeholders. 1hus each step should be taken in progressive numerical order but each step remains open to revision by subse"uent steps. 1he steps are related in a dialectical way in that the completion of one leads us to see inade"uacies in previous steps that need revision. 1he re"uirement to decide on a real time response to the situation sets a limit on how much of this dialectical thinking we can engage in. 1he proper response to a competitor$s marketing program may allow very little time for consideration whereas a decision on an affirmative action hiring policy may allow "uite a bit of time for consideration and revision. A De'/)i5tion o. the Seven Ste5' 1he following e&ample will be used in describing the seven steps' !tern Broducts, *nc. has for the past /: years paid the entire cost of health coverage for workers and their dependents. Recent increases in health

insurance premiums on the order of .4O per year have made this coverage a significant cost item on the firmDs income statement. 1he three members of the compensation committee are directed to review the health coverage policy and make recommendations at the ne&t board meeting. 1. The ,a/t'A a. What facts make this an ethical situation? What are the significant features of the particular situation which make it an ethical situation? *s there some actual or potential harm involved for an individual or group? #oes the situation relate to some basic human goods which are being created, distributed, denied or threatened? #oes the situation affect human welfare in some significant way? #oes it involve considerations of +ustice or rights? -ealth coverage for workers involves deciding how to divide up the goods of the corporation which is not only an economic "uestion of how to ma&imi%e the value of the firm but an ethical "uestion of what is the best distribution, the most +ust distribution, or the distribution which fulfills each groups rightful claims on the value of the firm. b. What facts are relevant to making an ethical decision? What facts should we know in order to decide how to act in this situation? !teps , and . are closely related. What facts are relevant will depend on what the ethical issues are and the ethical issues will be determined by the presence of certain facts. 1hus the initial assessment of facts will have to be augmented once the ethical issues have been determined. 1he facts in the !tern case would include' the cost to the company of the various coverage options, the short and long term economic prospects for the firm, worker demographics such as age, health status, level of economic sophistication, availability and cost of individual coverage, the effects of a change or lack of a change in coverage on the employees and the firm. 2. The Ethi/a0 7''&e'A a. What level of ethical issues are we dealing with' systemic, corporate, or individual? Pnowing the level of the problem will help us to decide who will be affected by the decision and will therefore "ualify as stakeholders and who will be re"uired to make the decisionFFthe society as a whole, decision makers within the corporation, or myself as an individual. 1he !tern case involves corporate level issues, though reflecting on the high number of uninsured persons in the society and how that impacts on the corporationDs cost of coverage may prompt the firm to get involved with the issue on an systemic level. b. What specific ethical issues does this situation raise? *s it a "uestion of how to ma&imi%e benefits and minimi%e harms. *s it a "uestion of whether an action can be universali%ed? ;f whether individuals are being treated as ends and not merely as means? ;f whether all rational persons would agree that a particular action is right or good? *s it a "uestion of a possible violation of rights or a conflict between rights? *s it a "uestion of the fair distribution of benefits and burdens? *s it a "uestion of how or whether to apply some specific ethical principle?

1he ethical issues could be stated as follows' (,) What level of health coverage do employees have a right to e&pect, given the history of the company? (.) What level of coverage will ma&imi%e worker productivity while contributing the most to the profitability of the firm? (/) !hould the firm involve itself in the national debate on health care coverage? c. What level of generality is re"uired? 1he ethical issues need to be stated at a level of generality which will allow the issue to be discussed in as broad a terms as possible, so as to see all the possible ramifications, while yet being specific enough to lead to alternative actions in the case at hand. 1he issue of health benefits for a corporationDs employees should allow reference to the standards of the society as a whole but should refer to a decision to be made by this particular corporation. /. 1he 9lternatives? Qiven the facts and the ethical issues, what alternative actions are possible in this situation? *nitially we should state as many alternatives as possible without making +udgments as to their plausibility. -aving generated as many as possible, the most plausible should be chosen for further e&amination. 1he corporation can provide no health benefits, coFpay with the employee, provide full benefits for the employee only, provide family benefits, open an -E;, and so on. 0. 1he !takeholders? a. Who will be affected by the alternatives and to what degree? We must determine who will be affected to a degree significant enough to include them among the primary stakeholders worthy of consideration. Mor systemic issues, which individuals, groups, institutions, and aspects of the physical, economic and social environment will be affected. Mor corporate issues, who and what inside and outside the corporation will be affected' stockholders, government, society, the environment, suppliers, customers, local community, employees, managers and so on. Mor individual issues, who will be affected

by the decision, both inside the company such as peers, superiors, other departments, and outside the company such as customers and suppliers. *n the health care e&ample, the stakeholders include the corporation as a viable economic entity, the stockholders, the employees, their families and the local community. b. -ow to rank stakeholder claims? Bart of the decision making process will be to establish how much weight each stakeholderDs claim deserves. 1his weighing of claims is often done intuitively. Mor purposes of +ustifying why the decision is the right one, however, the process for weighing the competing claims should be spelled out as much as possible. c. 1he firmDs claim on resources in order to continue as a viable economic unit would have be given the greatest weight, since without the firm none of the other stakeholders could receive any benefit. 1he competing claims of stockholders and workers would have to be given the ne&t greatest weight since they contribute directly to the value of the firm and have legitimate claims on that value. #eciding on how much weight to give each groupDs claims would re"uire and understanding of the capital structure of the firm (debtF Fe"uity balance, availability and relative cost of debt financing, and so on) and the history of the firmDs relations with the employees (degree of worker contribution to finished product, loyalty and productivity of workers, average length of employment and rate of turnover, and so on). Mamilies and the community would have less weight unless they have made e"ually important contributions to the firm. 4. 1he Ethics of the 9lternatives? a. <se ethical principles to decide on the best alternative. 1he ethics of each of the most plausible alternatives is assessed using ethical principles or rules. Mor each alternative, for e&ample, we could ask the "uestions associated with the utilitarian, rights and +ustice principles to determine how the alternative is rated by each theory. When the alternatives have all been rated as right or wrong, good or bad, the ob+ect is to select the best alternative. *n the ideal situation, all the ethical principles will point to the same

alternative as the best one.

<tilitarian Brinciple' Qiven the relative importance of the firm, the stockholders and the employees, which alternative would provide the greatest benefit to the greatest number? -ow would costs and benefits be measured in this case?

Rights Brinciple' What does each stakeholder have a right to e&pect with regard to health coverage? What alternatives would you not want imposed on you if you were in the position of any of the other stakeholders? Lustice Brinciple' Which alternative distributes the burdens and benefits most fairly among the stakeholders? Which stakeholders carry the greatest burden under each alternative? b. -ow to decide when the theories point to different alternatives. 1here are situations in which different ethical principles will recommend different alternatives. *n a case where the principles provide a mi&ed recommendation, we must choose which recommendation to follow and be prepared to +ustify that choice as best we can. Lustification can be provided by showing why the theory(ies) indicates that alternative as the best and how this fits better into our conception of what the good life is than the alternatives suggested by the other theories. *t may come down to the simple fact that, after inspecting all the alternatives with rationality and respect, * +ust do value one alternative, or one theoretical approach, or one point of view as highlighted by one theoretical approach, or one state of affairs provided by that alternative, or one value embodied by one alternative more than the others. * may not be able to say why * prefer that alternative e&cept in terms of the way * choose to live my life and what my e&perience has shown me. #oes the fact that * do not have another definite standard to appeal to, if two ethical theories should disagree mean that my decision is irrational or un+ustified? 5. 1he Bractical )onstraints? a. )an the best alternative be put into effect? -aving decided on one alternative, we need to see whether there are any practical constraints which might prevent that alternative from being acted upon. When practical constraints rule out an alternative, we must return to !tep 4 to select the ne&t best alternative and sub+ect it to the practical constraints test. 1he best alternative may be to pay employees the ma&imum practicable wages and let

them provide for their own health benefits. 1here may be a state or federal law mandating some level of company provided health coverage which would prevent our adopting this alternative. b. #istinguish ethical from practical constraints. Ethical decision making involves ruling out alternatives on ethical grounds in !tep 4 and on practical grounds in !tep 5. *n actual practice we often do not bother to distinguish the two different kinds of reasons for re+ecting an alternative. *t is be helpful to keep them distinct as far as possible in order to be clear as to what kind of reason we are giving. 1he difference between practical constraints and ethical considerations can best be illustrated by e&ample. *n deciding on the level of health coverage from a rights perspective, we would weigh the competing rights of employees and the stockholders to the benefits of the companyDs operations. 1his ethical consideration would be different, however, from asking the "uestion of whether the stockholders or the workers would agree to accept a particular division of the benefits. 6. 9ctions to 1ake? a. *mplementing the best alternative. -aving selected the best alternative which is not ruled out by practical constraints, we need to decide on the steps necessary to carry it out. *f a larger coFpayment by employees is the best alternative, how will it be implemented?

a. 9 summary of the +ustification. We should also be prepared, at the close of this decision process, to provide a +ustification of why this course of action is the right or good one in this situation. Qoing through the seven steps +ustifies the decision in the fullest sense. We should be prepared, however, to respond in some briefer form to the legitimate re"uests of othersFFour superiors, our peers, the agents of societyFFfor an e&planation of why this alternative is the best approach to this situation. 1his summary based on the seven steps will also provide us with a briefer account to apply to similar situations in the future. 1he worst punishment would be to face the full seven step

process for each and every ethical decision we make in our lives. We would have no time for living.

7. Ethi/a0 De/i'ion Ma1ing :0an( United States Department of Defense

,. #efine the problem. a. !tate the problem in general terms. b. !tate the decisions to be made. .. *dentify the goals. a. !tate shortFterm goals. b. !tate longFterm goals. /. ist appropriate laws or regulations. 0. ist the ethical values at stake. 4. Kame all the stakeholders. a. *dentify persons who are likely to be affected by a decision. b. ist what is at stake for each stakeholder. 5. Qather additional information. a. 1ake time to gather all necessary information. b. 9sk "uestions. c. #emand proof when appropriate. d. )heck your assumptions. 6. !tate all feasible solutions. a. ist solutions that have already surfaced. b. Broduce additional solutions by brainstorming with associates. c. Kote how stakeholders can be affected (loss or gain) by each solution. 7. Eliminate unethical options. a. Eliminate solutions that are clearly unethical. b. Eliminate solutions with shortFterm advantages but longFterm problems. 8. Rank the remaining options according to how close they bring you to your goal,

and solve the problem. ,:. )ommit to and implement the best ethical solution.

:L<S Mode0
B <! #ecision Eaking' !i& !teps to Ethical #ecision Eaking A !tep ,' #efine the problem B <! A !tep .' *dentify alternatives A !tep /' Evaluate the alternatives B <! A !tep 0' Eake the decision A !tep 4' *mplement the decision A !tep 5' Evaluate the decision B <! R1o make it easy to understand and apply the ethics filters we have adapted to mnemonic word B <!. A B S Bolicies *s it consistent with my organi%ationDs policies, procedures and guidelines?

S egal

*s it acceptable under the applicable laws and regulations? A < S <niversal #oes it conform to the universal principlesIvalues my organi%ation has adopted? A !S !elf #oes it satisfy my personal definition of right, good and fair?