Ethical Issues Hw
EmilyGD
Article_An_integrated_ethical_decision-making_model.pdf
Nursing Ethics
Volume 19, Issue 1, January 2012, Pages 139-159
© SAGE Publications 2012, Article Reuse Guidelines
https://doi.org/10.1177/0969733011413491
Article
An integrated ethical decision-making model for nurses
Eun-Jun Park
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 comparison; (4) the selection of the best alternatives and justification; (5) the development of diverse, practical 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,
professionals 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 professionals’ 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
1Kyungwon University, Korea
Corresponding author(s):
Eun-Jun Park, Department of Nursing, Kyungwon University, San65, Bokjeong-Dong, Sujeong-Gu, Seongnam-Si, Gyeonggi-Do,
461-701, Korea Email: [email protected]
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challenging for clinicians to make ethical decisions.
Health professionals attempt to achieve the best possible and morally-justifiable resolution while
prioritizing 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 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 decisions for several reasons.2,8–11 First, ‘a model functions as an intellectual device
that simplifies and clarifies 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 considering 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 explanation 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 (disagreements) 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 normative 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
recommendations 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 weaknesses 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 suggested 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
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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 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
outcomes. 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 participated 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 analyzed
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 practitioners, five for health
professionals in general, four for physicians, two for psychologists, one for social workers, and one for a
neonatal intensive care unit.
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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
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 professions.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 perform each step or which aspects to be considered in the field of healthcare
appeared insufficient. The number 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
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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 process 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 information 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 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
identification of ethical problem and then directly moved to the fourth stage of identification and
analysis of alternative 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 collected 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, decision makers can go back to the step of
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information collection.
Stages of selecting an alternative and evaluation. Sixteen models out of 20 included the fourth
stage of identification 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. Justification 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 Consensus in ethical decision can be obtained through a collaborative decision-making
process by communicating 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 application 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
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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 decision 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 professionals; 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 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,
professionals 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
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value conflicts should be clear. Accordingly, all possible alternatives/solutions are now suggested and
shared among stakeholders. 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 conscience 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 consequences, nurses cannot make an ethical decision based solely on
consequence and always have to take seriously 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 consistent 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 parties 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 confident 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. 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 addition, 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,
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and community/societal.
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 example 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 number 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
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clinical 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 suggested 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 consisting of six steps and including critical considerations to
satisfactorily accomplish each of those steps. Nursing 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
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.
Financial Disclosure
This research was supported by the Kyungwon University Research Fund of 2011 (KWU-2011-R172).
The author declares that there is no conflict of interest.
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Appendix 1. Integrated ethical decision-making model and its application with a clinical
example
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