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Ulrich-EthicsinEverydayPracticechapter2.pdf
EThICal dECISIoN-MakING: a fraMEWork for uNdErSTaNdING
aNd rESolvING MENTal hEalTh dIlEMMaS
–Marna S. Barrett, PhD Clinical Associate Professor of Psychology in Psychiatry
University of Pennsylvania Perelman School of Medicine
2
Think about It! • Ethical dilemmas are inherently troublesome, primarily because they involve at least two compet-
ing yet equally “right” choices rather than a right versus wrong choice.
• Distinct from other branches of medicine, psychiatry raises unique challenges for ethical decision- making. Only in mental health are we asked to determine a person’s competence, restrict a per- son’s right to self-determination, participate in legal decisions about a person’s culpability, and engage with society in a reciprocal relationship of influence.
• Ethical principles such as autonomy, beneficence, nonmaleficence, fidelity, justice, and empathy are ideals to which we strive. Although useful for understanding the complexities of a dilemma, they are not sufficient for problem resolution.
• A framework for ethical decision-making is imperative for developing a consistent and effective personal standard for resolving ethical dilemmas. Key elements of such a framework include identi- fying and clarifying the issue, determining whether the situation is a “right versus wrong” or a “right versus right” dilemma, evaluating the principles involved, creating a “trilemma,” weighing benefits and burdens, consulting, considering possible outcomes, making document decisions, and review- ing and reflecting on the process.
Ethical dilemmas are among the most difficult struggles we face. Whether in our professional or personal lives, we are confronted with decisions about what is right, fair, kind, and just. Within medicine, ethical dilemmas are more pronounced because of competing concerns such as benefit versus harm, the rights of individuals versus the rights of others, patient competency, patient versus hospital obligations, or truth versus kindness. In all ways, we are encouraged by our profession to strive toward the ideals of “compassion and respect for the inherent dignity, worth, and uniqueness of every individual” (American Nurses Association (ANA, 2001, para. 16). A formal code of ethics is what enables professionals to make clear to society the ethical obligations and duties that can be expected from us.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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18 Nursing Ethics in Everyday Practice
Being ethical, however, involves more than simply adhering to a professional code of ethics; it requires the infusion of personal virtues and ideals. For example, two nurses can follow the same mandate to respect others, yet someone who holds the personal ideal of autonomy and self-determination is likely to uphold a patient’s ideas, beliefs, and decisions, even if these are in conflict with the opinion of a colleague. Differing personal values help explain why conflict so frequently arises between two ethically sound individuals.
Although the Code of Ethics for Nurses (ANA, 2001) guides and directs our thinking about ethical be- havior, it provides little help in determining a course of action we should take when faced with a specific dilemma. In fact, what makes an ethical dilemma a dilemma is that two possible solutions exist, neither of which seems fully acceptable. Without some type of framework to guide the decision-making process, we are left to our own feelings, beliefs, hunches, and best bets about the “right” action.
In this chapter, I first discuss the general nature of decision-making, how decision-making differs in the context of a moral dilemma, and why a model of moral decision-making specific to mental health issues is needed. I then present the organizing principles of ethics and how they can be used to inform decisions. I then cover five models or frameworks for decision-making that are useful in addressing and resolving ethi- cal dilemmas across contexts or situations. I end with a case presentation using the practice-based model for decision-making, one that I have found to be comprehensive, easy to use, and widely applicable to ethi- cal issues in mental health.
decision-Making When faced with any decision, we generally follow three steps.
1. We identify the various alternatives for action. So, if I’m unhappy in my current position, I might consider quitting, moving to another hospital floor or unit, working on a different shift, or return- ing to school.
2. After all possibilities are identified, we review the potential outcome of each. For example, quitting might present financial difficulties, working a different shift might not be feasible given childcare responsibilities, and moving to another floor would mean switching from geriatrics to medical/ surgical.
3. Having considered all the possibilities and outcomes, we make a choice between the alternatives based on personal values and preferences. For example, although I am unhappy in my current position, I value the time with my children and believe that I am especially gifted in working with older patients. Therefore, I decide to remain where I am and look for ways to change the environ- ment so that I feel happier.
But how does decision-making related to moral or ethical issues differ? First, the dilemmas or uncer- tainties concern moral issues and, as such, are inherently personal. Although societies typically hold to a set of moral values, such as honesty, respect, kindness, fairness, and freedom, the range of values and the importance given to a particular value are unique to each individual. Whereas some people value honesty above all else, others value tolerance and appreciation of differences; and still others value faith, integrity, personal happiness, or hard work. Because morals influence our behavior, they are considered personal
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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19Chapter 2: Ethical Decision-Making
characteristics and thus carry emotional weight. When a dilemma arises that involves moral issues, we are faced not only with choosing among various alternatives for action but also with the emotion-laden values associated with any choice. In fact, the need for rationality (or reduction of emotion) in resolving ethical deliberations is the second factor unique to ethical decision-making.
Let’s re-examine the dilemma about work (presented earlier) with the knowledge that my unhappiness is primarily related to conflict with my supervisor. Although I am someone who is deeply proud of my work and feels a strong commitment to the people and hospital where I work, I respect authority and find it hard to confront my supervisor. With this information selecting a course of action becomes more com- plicated. Quitting my job would risk financial hardship and create a tension between my values of respect for authority and commitment to others. Considering a change in shift could create a conflict between my need for happiness and my commitment to fellow employees and to my children. However, a move to an- other floor in the hospital would allow me to maintain my values and meet the needs of my family. Thus, situations that involve moral and ethical concerns invoke such emotional connections to the issue that rationality and rigor in making any decision are warranted.
Mental health issues complicate the picture even more. Unlike any other aspect of medicine, psychiatry has unique moral and ethical issues (Fulford & Hope, 1994; Radden, 2002). In no other branch of medi- cine are assessments of the competency of patients to make decisions about their care required. Medical philosophers such as Thomas Szasz (1959) have argued that restricting a person’s right to self-determina- tion is worse than slavery. Yet psychiatrists are typically asked to make such decisions so that other medi- cal specialists can proceed with a particular course of action.
Mental health disciplines are also unique in that they play a role in legal issues—competency to stand trial, determination of sanity, or custody issues. Other than expert testimony, discussions of an individu- al’s physical or medical health have little place in the courtroom and are not influential in determining legal outcomes. Mental health problems, in contrast, frequently influence the courts in terms of sentenc- ing, guardianship, or responsibility for action.
Case Study 2 .1
Jim, a 65-year-old white man with beginning dementia, was hospitalized with diverticulitis. He was operated on and had an unremarkable recovery. As part of his discharge planning, he was to be given Oxycontin for pain. Jim did not think there would be much pain and didn’t want to take medication for fear that he would become dependent. Jim had recently seen a television show about addiction to painkillers and feared it might happen to him, since there was sub- stance abuse in his family. Jim refused the prescription for Oxycontin and was told that he could not be discharged without it. The more the nurse tried to get Jim to accept the prescription (whether or not he actually took the medication), the angrier and more suspicious he became about the reasons for the medication.
This case presents several ethical challenges. For instance, should the nurse continue to deny discharge to Jim unless he accepts the prescription, or should the policy be waived? Although discharge planning is routinely handled by the nurse, should Jim’s doctor be notified of the situ- ation and asked to override the order for pain medication? Given Jim’s problems with reasoning (i.e., beginning dementia), it might be useful to spend a few minutes educating him about the appropriate and safe use of pain medication. However, what should be done if he still refuses the prescription?
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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20 Nursing Ethics in Everyday Practice
Additionally, a reciprocal relationship of influence exists between society and mental health. The Di- agnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association (2000), offers a nosology for mental health disorders that determines the standard criteria by which behaviors are considered abnormal. By establishing such criteria, psychiatry influences what be- havior is seen as problematic, justifies the need for treatment, and affects third-party payment. Secondary effects of behavioral labeling are social stigma, forced treatment, isolation, and marginalization.
A recent example of the reciprocal influence with society is the diagnosis ofAsperger’s syndrome. Al- though considered a part of the autism spectrum disorders, Asperger’s syndrome was treated as a separate diagnosis in the DSM-IV because of the distinct symptomatic picture. This distinction resulted in greater awareness of the disorder, improved funding for research, and reduced stigma (Hamilton, 2010). How- ever, in considering revisions for the new DSM-5, researchers have suggested that Asperger’s syndrome be moved back under the rubric of autism spectrum disorders, because the basic difficulties with social engagement and language development are the same (Macintosh & Dissanayake, 2004). Not surprisingly, this suggestion has been met with considerable resistance and public outcry. Although many believe that the services available to individuals with Asperger’s syndrome would increase, the fear is that such a move would damage the considerable progress made in terms of reduced stigma and social acceptance for this disorder (Parenting Aspergers, 2010).
Ethical decision-making is, therefore, the attempt to decide between at least two competing courses of action that is complicated by personal values, strong emotions, and unclear guidelines. When occurring in the context of mental health, ethical decision-making is further complicated by the social, personal, legal, and organizational filters through which the situation must be examined. For these reasons, a framework to guide and inform ethical decision-making is crucial.
Ethical Principles Ethical principles are the standards that guide and promote the values held by a society, organization, or individual in determining what is right or wrong. Having their roots in ancient Greek philosophy, these principles are fundamental to Western bioethics (Beauchamp, 1999; Beauchamp & Childress, 2001) and form the basis for professional codes of ethics (Bloch & Pargiter, 1999).
• Autonomy refers to individuals’ rights to make choices about the nature and direction of their life without interference from others. Respect for autonomy means that we recognize and appreciate an individual’s perspective and capacities to hold certain views, make certain choices, and take action based on personal values, beliefs, and ideas.
• Beneficence is essentially seeing to the welfare of others. In medicine it requires us to act in ways that benefit others or are in their best interest. For example, patients benefit when we show mercy, kindness, or charity to them by alleviating their pain and suffering. Beneficence can also extend to aid we give in finding financial assistance or helping patients to gain access to health care.
• Somewhat in concert with beneficence, the principle of nonmaleficence requires action that does not bring harm to or hurt others. The balance between nonmaleficence and beneficence is one of the most common dilemmas within medicine, because most interventions or treatments involve the weighing of benefits versus risks.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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21Chapter 2: Ethical Decision-Making
• Fidelity refers to the act of faithfulness or loyalty. It is the trustworthiness people show in meeting their duties and obligations. Within medicine, fidelity also encompasses the trust patients place in us, the reliability and integrity of our treatments, and the manner in which these treatments are administered. Fidelity is of such importance that some have argued it is the foundation upon which all other ethical imperatives depend (Radden & Sadler, 2010).
• Justice can represent two types of behavior. Equal justice means treating all people the same without regard to any personal characteristic or behavior. Fairness refers to actions in which equal distributions of benefits, costs, and risks are made between individuals. For example, is a transplant list just in how it prioritizes individuals? Is it fair that someone of wealth can purchase a needed organ when others of lesser means are unable to do so?
• Although not always discussed as one of the fundamental ethical principles, empathy is a prin- ciple of behavior valued in medicine. Defined as the capacity to recognize and share the experi- ence of others, empathy demonstrates an understanding of people and identification with their feelings that has been shown to affect outcome.
Case Study 2 .2
Lisa, a critical-care nurse, is caring for Rochelle, a 73-year-old woman suffering from diabetes and multiple internal injuries following a serious motor vehicle accident. Although Rochelle had expressed to her husband and several friends a desire to not live in a situation as she was cur- rently, her husband was persuaded by the children to do everything possible to sustain her life. Rochelle’s husband has privately expressed to you his concern that her wishes are not being followed but feels he cannot disregard the wishes of their children.
What ethical dilemmas are raised in this case example? One challenge is whether or not Lisa should tell the doctors about Rochelle’s stated desires for limited life support, since it is hearsay from her husband. Should Lisa discuss the situation with Rochelle’s children? Should Rochelle’s treatment be altered? Each of these dilemmas involves competing ethical principles. For ex- ample, underlying the decision to discuss Rochelle’s desires with her doctors are the principles of beneficence (benefit to Rochelle by making her wishes known), fidelity (duty to disclose known information), and nonmaleficence (don’t harm Rochelle by giving her treatment she would not want). However, in regard to any decision to alter treatment, the principle of beneficence (do what is in her best interest) may conflict with the principle of nonmaleficence (do her no harm). What other conflicts do you see between ethical principles?
Ethical principles are ideals to which we aspire and encourage us to act in ways that better us as individuals and as a part of society. They provide a level of organization to our thinking about what is moral or right and help inform ethical decisions (Beauchamp & Childress, 2001). In fact, the reason ethical situations are so challenging is precisely because these principles underlie our thinking, and individuals differ in what is valued. However, it should also be recognized that ethical standards and ideals are not obligations. We have no responsibility to adhere to them, and they should not form the basis for imposing sanctions. That said, let’s now examine the ways these principles can inform our decisions.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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22 Nursing Ethics in Everyday Practice
Case Study 2 .3
Betty is a 45-year-old Caucasian female with bipolar disorder, type II, who works as a nurse practitioner for Tisdale Internal Medicine. Her mood state has remained relatively stable for the past 15 years, with brief periods of moderately severe depression followed by mild hypomanic episodes. Six months ago, Betty suffered the loss of her mother, with whom she had a close rela- tionship. She seemed to handle the loss well, but over the past month has become increasingly irritable, interrupting conversations and “talking over” others. She is currently full of energy, has several new ideas for improving office functioning, and feels the changes should be made im- mediately. Her demand for change has created tension among the staff, and patients have complained about her abrupt and somewhat dismissive behavior. Her boss, Dr. Mitchell, is aware of her recent loss, as well as her chronic mental health problems.
Dr. Mitchell is faced with the dilemma of determining how best to respond to Betty’s behavior. Should Dr. Mitchell talk with Betty about her behavior, or should he intervene with staff? If he talks with Betty, what does he do if she refuses to acknowledge her behavior as problematic? How much of her history can be shared with the staff? To what extent does confidentiality restrict his range of responses? Consider these questions as we review several approaches to ethical di- lemmas in the following section.
Ethics Principles Inform decisions Though meant to inspire us, ethical principles, such as those listed previously, also provide a basis for our thinking about ethical decisions. For example, the decision about how much to tell people prior to a surgical procedure, vaccination, or research participation (that is, informed consent) is grounded in the principles of autonomy, beneficence, nonmaleficence, justice, and empathy. Since the time of Aristotle and Plato, philosophers have argued about various ways to approach ethical situations that most benefit society. For example, from an Aristotelian perspective, society benefits when we recognize and further the goals we share in common, yet maintain respect for and value the freedom of individuals to pursue their own goals. Referred to as the fairness or justice approach, decisions are based on a determination of which action treats people most fairly.
Expanding this idea a bit further, the common good approach asks us to consider which action con- tributes most to the quality of life for the people involved. For example, of the number of ways to address the situation with Betty (Case Study 2.3), a common good approach would suggest that Dr. Mitchell talk with Betty about the effect her behavior has had on the office and encourage her to take time off and seek treatment.
A second major approach to ethical dilemmas is the act utilitarian or ends-based model. Utilitarian thinking requires consideration of which action brings the most benefit to the most people and incurs the least harm. Immanuel Kant was the main proponent of this approach and argued that in aspiring to higher principles, we need to consider our duties to others as well as to ourselves. If our motives are moral, then the outcome is considered moral and right. Applying this approach to the situation with Betty, Dr. Mitchell might decide to intervene more directly because of concerns about his patients as well as the staff. He could talk with Betty about her behavior and determine whether she needed to get treatment, if she was not already doing so. Although Dr. Mitchell values autonomy, in trying to balance the greatest benefit with the least harm he decides to override Betty’s dismissal of the problems and calls her family.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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23Chapter 2: Ethical Decision-Making
A slightly different perspective to the ends-based model is referred to as rule utilitarianism. From this perspective, decisions are based on how much good is done by a particular action in regard to a rule or law. The premise is that the rules of society are in place to maintain order and are therefore to be respected and valued. For example, euthanasia, the ending of life to relieve pain and suffering, is legally wrong in this country. In deciding whether or not to continue life support of a comatose patient, a person following rule utilitarianism would consider how much society would benefit if life support were removed against the law.
A third major approach to ethical decision-making is rule-based or deontological thinking. This ap- proach requires that we consider an action based on whether or not we would be comfortable with our action becoming law. In other words, the morality or ethic of an action is judged not on consequences, but on the principles that underlie the action. For example, in resolving the dilemma with Betty, Dr. Mitchell would determine a course of action consistent with his morals and values and one with which he would be comfortable as a standard for action.
Focusing more on individual character, the virtue-based approach to ethical decision-making encour- ages us to act in ways that are consistent with the person we want to be. Rather than focusing on the results of any action, virtue-based ethics focuses on becoming a person of good character. If Dr. Mitchell, in Case Study 2.3, held to a virtue-based approach, he might ask, “What kind of person should I be?” or “What ac- tion will promote the development of high moral character in me and my community?” or “If I take this ac- tion, will I become more like the person I want to be?”
The fifth major approach to ethical dilemmas is based on the principle of care (that is, the golden rule). Care-based thinking demands that we act in ways consistent with how we would want others to act toward us. This perspective considers inequalities in relationships, and priority is given to humane treatment that upholds the respect we all deserve as human beings. Applying this approach to the ongoing example of Betty, Dr. Mitchell would likely seek to understand how he would feel if he were Betty and base his decision for action on this understanding. Therefore, he might decide to talk with Betty about her behavior, help her to appreciate the negative effects brought on by the behavior, and together determine a course of action.
Why Are Ethical Decisions So Difficult? Given the usefulness of ethical principles in informing decision-making strategies, why do we struggle so with these issues? Rushworth Kidder, in his book How Good People Make Tough Choices (1995), has articulated a simple yet poignant answer—most ethical dilemmas are not struggles of right versus wrong, but right versus right. Most of us have a fairly clear sense of what is right and wrong. Lying, cheating, and stealing are wrong. Respecting others, telling the truth, and being kind are right. However, at times we struggle with even these issues. For example, should you tell a patient about the availability of less invasive procedures when the physician they have seen always recommends surgery? Should Dr. Mitchell disclose his concerns about Betty to her family?
Despite such questions, most ethical dilemmas leave us unsure about a particular course of action pre- cisely because they involve two competing “right” choices. For example, upholding patient confidentiality is right. However, breaking that confidentiality if it is for the protection of others (for example, HIV status, child abuse) is equally right. If you break confidentiality, the patient might no longer trust you and the therapeutic relationship will likely be damaged. If you don’t break confidentiality, however, others might be
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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24 Nursing Ethics in Everyday Practice
hurt. Unfortunately, few clear legal mandates for taking a particular course of action exist, and our profes- sional codes of ethics offer little in the way of specific guidelines for resolving dilemmas.
four Paradigms underlying right versus right dilemmas
1. Truth versus loyalty
2. Individual versus community
3. Short-Term versus long-term goals
4. Justice versus mercy
One way to begin to understand why “right versus right” dilemmas are so problematic is to recognize that often underlying these issues are competing moral paradigms. For example, being truthful is right and being loyal is equally right. Consider a scenario in which you’ve become aware that your agency is billing Medicare for therapy sessions that are not conducted in person, but over the phone. Providing some sessions by phone is the only way the psychiatrist can offer immediate care to patients in need. The dilemma, however, is whether you should be truthful and disclose the practice to Medicare or appreciate the efforts of the psychiatrist to provide care and maintain loyalty to the physicians and agency.
Another paradigm often underlying ethical dilemmas is the tension between an action that benefits the individual versus one that benefits the community. In my work with patients having bipolar disorder, I often struggle with the decision about hospitalization. Do I respect the autonomy and self-direction of the individual to decide whether or not hospital support is needed to control the manic behavior, or do I restrict his or her autonomy in favor of beneficence and decide that hospitalization is necessary for the welfare of the patient and community? This scenario might also be viewed as a struggle between benefi- cence and nonmaleficence. That is, do I help or harm the patient by allowing continued interactions that increase the likelihood of arguments, fights, uncontrolled spending, or other high-risk behavior? Is there a way I can help the patient, respect autonomy, and reduce the risk of harm? These are the issues that cause us discomfort and often lead to disagreements with others.
A third competing moral paradigm is that of short-term versus long-term goals. In my own life, decid- ing whether I should spend a Sunday afternoon writing papers that would further my career (a long-term goal) or spend an enjoyable day with my family (a relatively short-term goal) is an almost routine struggle. In the previous scenario about Medicare, the dilemma of greatest discomfort for the nurse might not be truth versus loyalty, but the conflict between her immediate need for employment (that is, I might be fired if I disclose the billing practices) and her long-term feelings about personal character (that is, I am becoming a bad person if I stay quiet and do not disclose something unethical). This situation highlights another important issue in understanding ethical dilemmas in that one issue can often be complicated by multiple competing paradigms.
One final paradigm often presenting itself in ethical dilemmas is that of justice versus mercy. This struggle is frequently at the heart of many jury deliberations. For example, should someone with schizo- phrenia be held accountable for his or her actions if he or she chose not to take prescribed medication? Should the sentence be lessened simply because of the diagnosis? The justice versus mercy debate is also
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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25Chapter 2: Ethical Decision-Making
central to decisions about removing life support or assisting the death of a terminally ill patient. Provid- ing needed medical care is right and fair, and showing mercy by allowing a person to die with dignity is equally right and fair.
Although these are just a few of the more frequently occurring competing moral paradigms, this discus- sion clarifies why ethical dilemmas are so difficult and why we often disagree with respected friends and colleagues when faced with such a situation. Unfortunately, knowing why ethical issues are problematic does not get us any closer to knowing how to resolve them. Although professional codes of ethics, laws, and our own moral compass provide some guidance, they do not help in resolving the majority of issues we face, particularly in the area of mental health. Not knowing how to act when confronted with the gray areas of ethics is one of the main reasons I began to explore models of decision-making used in philosophy and business, with the hope that these might be applicable to mental health dilemmas.
Models of Ethical decision-Making A number of frameworks are useful in guiding decision-making; however, five models seem particularly appropriate when facing mental health decisions. These include the standards-based model, the principles- based model, the virtues-based model, the moral reasoning-based model, and the practice-based model. As a way to better understand and appreciate the strengths and limitations of these approaches, presentation of each model will incorporate discussion of the model’s relevance to Case Study 2.4.
Case Study 2 .4
Mr. Stevens is a 66-year-old divorced Caucasian man living alone. He has three grown children who live outside the state. Until 2 years ago, Mr. Stevens worked as a high school English teacher at a private school where he had been employed for 35 years. He took early retirement because of ill health and recently underwent cardiac bypass surgery for several blocked arteries. His re- habilitation following surgery went well, although he developed a severe depression during his stay in the rehabilitation facility. He has few friends and now is even more withdrawn, remaining isolated in his apartment watching TV. His financial situation has worsened, because he has been unable to find part-time employment and has little in savings. At a recent visit to his cardiologist, he mentioned to the nurse practitioner, Sophia, that he does not like taking “so many pills” and sometimes misses a dose. In passing, he mentioned that he would be better off if he had another heart attack and died. When Sophia suggested he speak with a mental health professional, Mr. Stevens said that he does not believe he is depressed, but just “worries some.” He then stated quite adamantly that he did not want to burden his family with concerns of his situation.
Sophia is faced with several issues. Should she intervene with Mr. Stevens’ family? Is treatment needed for Mr. Stevens? Is hospitalization warranted? Do social services need to be involved? How should Sophia handle questionable compliance with treatment? How might his recent sur- gery have influenced the depression, and does this impact her decision for intervention?
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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26 Nursing Ethics in Everyday Practice
Standards-Based Model
The standards-based model for decision-making rests on the assumption that rules, laws, and policies provide the best basis for determining action. By holding to a standard set of rules for conduct, few situations are seen as ambiguous, and the only question to ask oneself is whether or not the situation warrants deviation from those rules. From this perspective, the first step in making a decision is to determine the primary dilemma. This might seem somewhat intuitive, but situations are often complicated by the presence of multiple clinical, social, legal, and ethical issues that often cloud our ability to appreciate the main dilemma to be addressed. For example, the case of Mr. Stevens involves issues related to suicidal thoughts, depression, the taking of medication, financial hardships, and lack of insight. However, the primary issue is whether or not to force some type of mental health treatment.
Standards-Based Model
1. Determine the primary dilemma.
2. What standards apply?
3. Determine a course of action.
4. Is there a reason to deviate?
Once we identify the key issue, the second step we take is to specify the standards that apply to the situation and determine whether we have reason to deviate. In Mr. Steven’s case, the standard rule of care would be to arrange for a mental health appointment and follow up with him regarding compliance. Hav- ing determined the course of action, we can now ask if we have any reason to deviate from this standard. At this point, the model often fails us. For example, how severe does Mr. Stevens’ depression have to be before we take a different action? Is his social isolation and firm decision not to inform his family enough to warrant deviation? Do we need to consider his denial of depression? With these questions in mind, we can examine a second model.
Principles-Based Model
A principles-based approach to decision-making relies on the philosophical principles of autonomy, beneficence, nonmaleficence, justice, loyalty, and empathy to guide our ethical thinking. There are four major steps in a principles-based approach: clarify the dilemma, evaluate the situation, decide on a course of action, and act. As with the standards-based approach, one of the first steps in addressing any dilemma is determination of the primary issue. In the example of Mr. Stevens, the key dilemma is whether or not to force some type of mental health treatment.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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27Chapter 2: Ethical Decision-Making
Principles-Based Model
1. Clarify the dilemma.
2. Evaluate the ethical principles/factors involved.
3. Decide on a course of action.
4. Act.
Having identified the primary problem, the principles-based approach probes more deeply into the issue and requires consideration of the ethical principles and values involved. In the case of Mr. Stevens, the underlying principles are autonomy (respecting his right to make decisions about his care), benefi- cence (act to benefit him), loyalty (to Mr. Stevens), truthfulness (to Mr. Stevens’ family), and empathy. Knowing which principles are involved can help us clarify the dilemma and better evaluate the factors involved. For example, Sophia, the nurse practitioner, might need to ask Mr. Stevens for more informa- tion about why he doesn’t want his family involved and how he understands his “worries,” to distinguish facts from beliefs and opinions. This information can also help in weighing the benefits and burdens of any particular course of action, such as whether Mr. Stevens should be started on medication, his family should be notified, or social services should be contacted. Because the principles-based approach focuses on ethical principles, deciding on a particular action involves prioritizing of principles, which might differ between individuals. For example, Mr. Stevens’ cardiologist might hold beneficence as primary, whereas Sophia might regard autonomy as paramount, thereby leading to differing decisions for action. In this case, considering the worst case scenario and potential consequences of a specific choice might be helpful, although a decision still might not be reached. The inability to resolve dilemmas because of competing ethical priorities leaves us in no better position than before we examined the dilemma and is a significant limitation of the principles-based model.
Virtues-Based Model
The virtues-based model considers that our dispositions and habits enable us to act according to the highest potential of our character and on behalf of our values. In other words, the kind of person that I am and strive to be determines how I act. From this perspective, we ask two major questions in dealing with an ethical dilemma: Which of X, Y, or Z choices are most consistent with my values or virtues? What kind of person will I become if I take X, Y, or Z action? Recall that virtues encompass behaviors or characteristics such as autonomy, beneficence, empathy, fidelity, justice, and nonmaleficence. In regard to the situation with Mr. Stevens, Sophia would be encouraged to examine her personal values and determine which course of action is most consistent. If she prides herself on being an empathic person who respects individual rights, Sophia might be more inclined to arrange for treatment or hospitalization for Mr. Stevens than to involve outside agencies or his family. However, if she holds strongly to truthfulness and connection to others, Sophia might be more likely to alert Mr. Stevens’ family to his condition and encourage Mr. Stevens to involve them in any discussions about treatment.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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28 Nursing Ethics in Everyday Practice
virtues-Based Model
1. What kind of person will I become if I take a particular course of action?
2. What course of action is most consistent with my virtues?
3. Act accordingly.
Either approach would be appropriate and “right,” although vastly different outcomes are likely to re- sult. Therefore, one of the major limitations of the virtues-based approach is that it relies on the virtues of each individual to determine a particular course of action. If the dilemma involves only a single person, the model can be useful. However, the greater number of people involved in the process, the more difficult it is to reach agreement, because everyone differs to a greater or lesser extent in the virtues to which they strive.
Moral Reasoning-Based Model
The moral reasoning-based approach to ethical dilemmas, proposed by Jones (1991), argues that individuals reason on a higher moral level when the perception of moral intensity increases. In other words, the extent to which an individual is immersed in the ethical dilemma, the perceived importance of the issue (that is, risk for harm, social consensus), the immediacy of action, and the degree of impact (amount of harm or benefit) all factor into the level of moral reasoning used in resolving a dilemma. Given that ethical decision-making requires considerable time and effort, Jones argues that we rely on lower levels of moral reasoning (for example, self-interests, social expectations) when an issue is less intense and higher order reasoning (for example, ethical principles, abstract thinking) when the perception of intensity is high. Stated more simply, when the stakes are high, we give greater thought in determining a course of action.
Moral reasoning-Based Model
1. Recognize the moral issue and determine that action is needed.
2. Determine level of involvement.
• Individual & situational variables
• Factors of opportunity
3. What is the effect of the decision on others?
• Impact an individual or group
• Likelihood of harm
• Closeness to the issue
• Agreement with social norms
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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29Chapter 2: Ethical Decision-Making
Relying on the moral reasoning-based model, how might Sophia approach the situation with Mr. Ste- vens? What level of moral intensity might she perceive? As with several of the models, we must first rec- ognize that a situation involves a moral issue requiring us to act. The moral reasoning approach then asks that we determine our level of involvement in the dilemma by assessing individual and situational factors. For example, because the situation with Mr. Stevens involves issues related to his care, both Sophia and the cardiologist are likely to be involved in the decision-making. However, because Mr. Stevens disclosed his feelings to Sophia and she has a relationship with him, she is in a better position than the cardiolo- gist to intervene. The next major step is to determine the effect of any decision on others. For example, although Mr. Stevens’ family would be affected if the decision was made to contact them or pursue hospi- talization, the main person affected by any decision is Mr. Stevens. Also involved in determining the effect of a decision is whether harm might come to Mr. Stevens as a result. Although physical harm is unlikely, Mr. Stevens could well suffer from forced treatment, unwanted interactions with his family, or challenges to his self-esteem. In regard to the issues, the need for treatment and potential for self-harm are important social concerns, and a decision to contact Mr. Stevens’ family, refer him for treatment, or hospitalize him if at risk for suicide would be deemed by most of society as appropriate courses of action.
Two final considerations are whether the decision needs to be made immediately and the severity of its impact. The question of immediacy is fairly straightforward. Mr. Stevens does not report clear intent or plan for suicide and is functioning well, albeit with some limitation. So those involved have time to con- sider various options and to even meet with Mr. Stevens again. Despite these less immediate concerns, the decision does have fairly significant consequences for the doctor-patient relationship, relationships with family, Mr. Stevens’ self-perception, and follow-through on treatment. So the moral intensity of the situ- ation for Sophia is moderately high and requires more than consideration of her interests and desires or those of society. Although Sophia needs to give considerable thought before acting, she is still left to make a decision without much more guidance than consideration and prioritization of her ethical principles.
Practice-Based Model
Each of the models discussed so far is useful for guiding our understanding of ethical dilemmas and the issues involved, but none addresses the fact that most dilemmas involve tension between two competing “right” choices. Furthermore, none of the models is comprehensive enough to facilitate decision-making across a number of different situations or contexts. Because legal mandates, professional guidelines, and personal virtues provide only a modicum of direction when we are faced with an ethical dilemma, and any decision we make can be and often is scrutinized and challenged, we need to develop a model for ethical decision-making that is comprehensive, yet simple enough to allow a “standard for action” that we can routinely follow.
• Immediacy of action
• Severity of impact
4. Act.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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30 Nursing Ethics in Everyday Practice
The practice-based model, developed from the work of Rushworth Kidder (1995), incorporates the key aspects of the standards, principles, virtues, and moral reasoning-based approaches into a simple frame- work based on the premise that most dilemmas are not moral issues of “right versus wrong,” but rather “right versus right” dilemmas. In the dilemma confronted by Sophia, the practice-based approach would suggest that she first ask whether or not the situation involves a moral issue. Though this might seem rather superfluous, many dilemmas are primarily clinical or legal concerns rather than moral ones. For example, maintaining confidentiality in the therapeutic setting is a clinical mandate. However, if I have knowledge about child abuse or the potential for harm, I am legally mandated to break confidentiality and report the information—regardless of any ethical or moral concerns. In the case of Sophia and Mr. Stevens, the issue involves both ethical (for example, disclosure) and clinical concerns (compliance, treatment). Having clarified the ethical concerns, I can now address the appropriate issues.
Practice-Based Model
1. Recognize the moral issue.
2. Determine the individuals involved.
3. Gather the relevant facts.
4. Test for right versus wrong issues.
5. Test for right versus right paradigms.
6. Determine resolution principles involved.
7. Investigate “trilemma.”
8. Weigh benefits & burdens.
9. Consult.
10. Consider dilemmas resulting from action.
11. Make the decision.
12. Formulate a justification for the decision.
13. Document.
14. Review & reflect.
From a moral reasoning or practice-based perspective, the next step would be consideration of the moral intensity of the dilemma. Who are the individuals involved? How immediately is a decision need- ed? What is the potential impact of this decision? As you might recall, we determined previously that So- phia’s dilemma was moderately intense and, therefore, requires careful moral consideration. So, what are the relevant facts? Mr. Stevens is depressed, not functioning well, withdrawn from family and friends, and has passive suicidal thoughts. Sophia is the only person to whom this information is known. Sophia works for the cardiologist who recently operated on Mr. Stevens. Mr. Stevens does not appreciate the severity of his depression and has adamantly stated that he does not want his family informed.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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31Chapter 2: Ethical Decision-Making
Having identified the key players in the dilemma and the facts involved, we return to consideration of the moral and ethical concerns. Is the issue of disclosure a “right versus wrong” decision, or is it a “right versus right” dilemma? One quick test helpful in making this determination is what Kidder (1995) has referred to as the “front page” test. Stated more fully, I ask, “Would I be comfortable having my decision published on the front page of the paper?” Although some nurses might view disclosure as a clear-cut “wrong” decision, most would agree that the issue of disclosing Mr. Stevens’ depression is not so straight- forward and encompasses competing “right” choices. But what are the “right” choices?
As discussed earlier in the chapter, four basic paradigms underlie “right versus right” dilemmas and all underscore the dilemma with Mr. Stevens. For example, Sophia wants to be truthful about Mr. Stevens’ situation but also feels loyal to him and respects his right to privacy. Although the decision about disclo- sure primarily involves Mr. Stevens, Sophia must also consider the implications for Mr. Stevens’ family and the cardiology practice. Mr. Stevens’ short-term needs are for improved functioning and self-care. Equally important, however, are long-term goals of family support, health, and happiness. Finally, tension exists between justice and mercy. Although Sophia wants to be just and fair in getting Mr. Stevens what- ever care he needs, she also feels merciful toward him and wants to respect his wishes.
Having gained a better understanding about the “right versus right” nature of her dilemma, Sophia can now reflect on the ethical principles she values and how these influence her thinking. Awareness of the underlying principles can also help Sophia in her discussions with the cardiologist, who might disagree with her about an appropriate action. From an ends-based approach, Sophia might decide to do whatever is necessary to get Mr. Stevens the treatment he needs for his depression. However, notifying Mr. Stevens’ family against his will might not be a “rule” for action that Sophia would want adopted, and thus, she might consider how she would want to be treated if in the same situation. If she values an individual’s right to self-determination, Sophia would likely seek ways to support Mr. Stevens’ decision while also get- ting him the care he needs.
Sophia now has a clear perspective on the dilemma, its ethical underpinnings, and the issues with which she struggles in reaching a decision. At this point, she must consider a course for action. One of the most useful aspects of Kidder’s approach to decision-making is the suggestion that, rather than focusing on the two-choice “dilemma,” we instead focus on the “trilemma” in which multiple (at least three) pos- sibilities for action are explored. Demanding that consideration be given to at least three options frees us from the “either or” mentality and allows us to be creative in developing strategies for resolution.
For example, rather than Sophia deciding between disclosure or nondisclosure of Mr. Stevens’ depres- sion to his family, she might decide to talk with Mr. Stevens about her concerns and educate him about depression. She could also discuss various ways to help his worry that would be agreeable to him (for example, increase his daily activity, encourage time with friends or family, arrange for him to attend a sup- port group, give him referrals for therapy, consider medication). Sophia could also schedule an appoint- ment for Mr. Stevens to talk with the cardiologist about his worries or arrange for him to meet with his primary physician, if he has a good relationship there. As this example illustrates, encouraging exploration of actions beyond the initial dilemma lessens the emotional intensity of the situation and fosters clearer perspective. Some of the most complicated decisions I have faced have been resolved in the most satisfy- ing way solely because I pushed myself to develop at least three ways for action.
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32 Nursing Ethics in Everyday Practice
Having several strategies for dealing with Mr. Stevens’ depression, Sophia must now make a decision. How does she decide? As with any decision, the benefits and costs of each decision must be considered. If Sophia decides to delay disclosure and arranges for Mr. Stevens to talk with his family doctor, how does she know that he will follow through? What if nothing comes of the meeting? What is her obligation to Mr. Stevens beyond the referral? In weighing the risks and benefits of any decision, I have found it ex- tremely useful to consult with my colleagues. Not only does this give me fresh perspective on the situa- tion, but in this age of unrestrained litigation, consultation allows the blame for any decision to be shared. This might sound rather harsh, but sharing the burden for a decision can be reassuring, provide me with professional support, and lend credence to my decision as a standard to which others agree (Hedges, 2007).
One last consideration before making the decision is to reflect on the potential consequences of the ac- tion. More specifically, considering whether additional dilemmas might arise as a result of the decision is often helpful. For example, Sophia does not know how Mr. Stevens’ family will respond if she decides to contact them. What does she do if they are angry with Mr. Stevens for not notifying them sooner? What if they are not interested? If she decides to refer him to his primary physician, what does she do if Mr. Stevens does not keep the appointment? What if the physician doesn’t recognize the severity of his depres- sion? Giving thought to potential outcomes allows us to recognize possible shortcomings of a decision and to anticipate possible objections.
Reflective Practice
1. How would you prioritize the moral paradigms underlying Sophia’s dilemma?
2. What ethical principles would guide your decision-making?
3. What other ways could Sophia’s concerns about Mr. Stevens be addressed?
adapting the Practice-Based Model
Don’t let the number of steps in the model scare you. It is comprehensive but can be shortened to quickly address whatever dilemma arises. You will also find that after only a few applications of the model, the steps flow fairly naturally.
Having carefully considered all aspects of the dilemma, it is now time to make the decision. However, our work is not yet done. Given that few mandates for action exist and most dilemmas are in ethical gray areas, decisions such as these need to be documented and defended. By clearly articulating the steps taken in reaching the decision, alternatives for action considered, justifications for the decision, limitations of the decision, and consultations, the seriousness with which the action is considered is demonstrated. Such behavior will not necessarily prevent legal or professional sanctions should others disagree with the deci- sion. However, delineating the care taken in reaching a decision and having a set model by which we ap- proach ethical dilemmas allow us to act in ways that are consistent with who we are and who we want to become. Even without clear moral or legal guidelines for behavior, we can act in virtuous ways.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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33Chapter 2: Ethical Decision-Making
Finally, we need to review the decision-making process and reflect on the outcome of the decision after the situation has resolved. What aspects of the situation were overlooked? Were there issues we failed to consider? How could this be avoided in the future? Were we able to consider the situation objectively? Are there ways the model could be altered to better aid our decision-making? Such reflection allows us to develop an approach to decision-making that is malleable, relevant, and personal. For example, when I am confronted with an ethical dilemma, all too often the emotion of the situation is so compelling, I fail to take time to carefully think the situation through and instead quickly jump to a decision. Because of this tendency, my own model of decision-making starts with the admonishment to “STOP. Take a deep breath.” Only a few seconds of stepping away from the issue allows me to more carefully address the perti- nent aspects of the situation and make an informed decision.
Conclusion Throughout this chapter we have discussed the ethical challenges faced by nurses and how such dilemmas can be resolved. Although a formal code of ethics delineates expectations for behavior, our personal virtues and ideals are what enable us to act ethically. However, two ethically sound individuals may disagree on a course of action precisely because their personal values differ. Reaching a decision about an ethical situation is further complicated because typically there are at least two competing, equally right choices rather than a right and wrong choice.
Ethical decision-making is particularly challenging in the field of psychiatry. Only in mental health does society influence diagnostic decisions and ask us to make judgments about competence, right to self-determination, and culpability. Thus, a framework for understanding and addressing mental health dilemmas is imperative if we are to have a standard of care for consistent and effective resolution. Build- ing on four major models of decision-making, the practice-based approach to ethical decision-making incorporates the ethical principles of philosophy into the practical decision-making strategies of business. Key elements of such a framework include identification and clarification of the issue, distinction between a “right versus wrong” or “right versus right” dilemma, evaluation of the principles involved, creation of a “trilemma,” weighing of benefits and burdens, consultation, and consideration of possible outcomes. Following a decision, it is critically important that we document the steps we took in making the decision and give time to review and reflect on the process.
I encourage you to use the principles, paradigms, and models discussed in this chapter to develop your own framework for ethical decision-making. Not all of these will be applicable to you, your specialty, or your work setting, but they can offer a foundation from which you can create a personal model for effec- tively confronting and dealing with ethical dilemmas.
Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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34 Nursing Ethics in Everyday Practice
Talk about It!
• Think about the last week you worked. What ethical situations did you face? Did any in- volve “right vs. wrong” decisions or “right vs. right” dilemmas? What was the resolution? How did you feel about the process and/or outcome? Share your explorations about this situation with a colleague or your team. Discuss the different reactions each of you had regarding the situation.
• Think about one particularly challenging ethical situation.
• Which ethical principles were involved?
• What were the competing moral paradigms?
• What courses of action were considered?
• How might it have helped to apply one of the models discussed in this chapter?
• In what ways would the models be less helpful?
• Explore this situation with someone in your life who is nonjudgemental but is thoughtful of similar situations so that you can explore the situation with a “devil’s advocate.”
• Discuss this same situation with a trusted colleague to explore the ethical principles he or she values, what approach he or she would likely take, and what creative ideas for resolution he or she offers. In what ways do you agree or disagree?
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Ulrich, C. M. (2012). Nursing ethics in everyday practice : A step-by-step guide. Sigma Theta Tau International. Created from apollolib on 2023-01-10 05:55:03.
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