ETHICAL DECISION MAKING

Chinn, 1995
Peace requires that you do what in your heart
you know that your chosen values guide
your actions.
Learning Objectives
Describe and differentiate ethical dilemmas,
moral uncertainty, practical dilemmas, moral
distress, and moral outrage.
Describe the process of making thoughtful
decisions.
Discuss the nursing process as a decision making
model.
Discuss similarities between scientific process
and ethical decision making
Examine the process of ethical decision making.
Apply the ethical decision making process to
clinical case situations.
Introduction
Everyone makes decisions as part of eveyday
living.
Nurses constantly make decisions such as:
management of care, when to collaborate,
when to innate referrals, etc.
Often we make decisions without conscious
awareness of the process but have an innate
sense of knowing what to do.
Moral / Ethical Problems
Jameton (1984) describes 3 different types of moral
problems:
1. Moral uncertainty: nurse identifies a moral
problem but is unsure of the morally correct
action.
2. Moral distress: when two or more mutually
exclusive moral claims clearly apply and both
seem to have equal weight.
3. Moral outrage: nurse knows the morally correct
action and feels a responsibility to the patient, but
institutional or other restraints make it nearly
impossible to follow through with appropriate
action.
Making Decisions
The process follows a similar pattern in most
circumstances, includes: gathering data,
comparing options, using some criteria for
weighing the merit f each option, and making
a choice.
Evaluation of outcomes provides more data
regarding the rightness of the choice.
Nursing Process and Ethical Decision
Making
As a nurse we commonly use the nursing process
model for decision making.
Utilizing both logical thinking and intuitive
knowing.
Nursing process directs nursing practice,
standardizes nursing care, and unifies nurses.
Nursing process steps by ANA: 1) Problem
identification based on assessment of subjective
and objective data; 2) Determine desired
outcomes; 3) Development of a plan for care; 4)
Implementation of interventions; 5) Evaluation of
the outcomes and revision of the plan over time.
Ethical Decision Making
Differences of culture or values among the
various participants involved in ethical
decision making often become an important
issue.
Holistic view of people, both thinking and
feeling are credible ways of knowing have
legitimate role in ethical decision making.
Process of Ethical Decision Making
1. Gather data and identify conflicting moral
claims
2. Identify key participants
3. Determine moral perspective and phase of
moral development of key participants
4. Determine desired outcomes
5. Identify options
6. Act on the choice
7. Evaluate outcomes of action
A Guide for Decision Making
Gather Data and Identify Conflicting Moral
Claims:
What makes this situation an ethical problem?
Are there conflicting obligations, duties,
principles, rights, loyalties, values, or beliefs?
What are the issues?
What facts seem most important?
What emotions have an impact?
What are the gaps in information at this time?
Identify Key Participants:

Who is legitimately empowered to make this

decision?
Who is affected and how?
What is the level of competence of the person
most affected in relation to the decision to be
made?
What are the rights, duties, authority, context,
and capabilities of participants?
Determine Moral Perspectives and Phase of
Moral Development of Key Participants

Do participants think in terms of duties or

rights?
Do the parties involved exhibit similar or
different moral perspectives?
Where is the common ground? The
differences?
What principles are important to each person
involved?
What emotions are evident within the
interaction and with each person involved?
What is the level of moral development of the
participants?
Identify Options:
What options emerge through the assessment
process?
How do the alternatives fit the lifestyle and
values of the person(s) affected?
What are legal considerations of the various
options?
What alternatives are unacceptable to one or
all involved?
How are alternatives weighed, ranked, and
prioritized?
Determine Desired Outcomes:
How does each party describe the
circumstances of the outcome?
What are the consequences of the desired
outcomes?
What outcomes are unacceptable to one or all
involved?
Act on the Choice:
Be empowered to make a difficult decision
Give yourself permission to set aside less
acceptable alternatives
Be attentive to the emotions involved in this
process
Evaluate Outcomes of Action
Has the ethical dilemma been resolved?
Have other dilemmas emerged relate to the
action?
How has the process affected those involved?
Are further actions required?
Case Study
Application of the decision making guide in
clinical situations is illustrated in the following:
A couple is pregnant with their second child
after numerous unsuccessful attempts with
artificial insemination. During a routine
ultrasound at 28 weeks gestation, the
physician discover that the fetus is
anencephalic. The life expectancy of an
anencephalic baby is only a few days to weeks
after birth. The couple struggles with the
choice to terminate the pregnancy at this time
or to carry the child to term.