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Unit 2 HCM641 IP Due Tuesday, 11.27.18:

An Appalachian patient in your health care facility wishes to stop treatment for his stage 4 bone cancer. His family is adamant that he continue the treatments. There have been multiple incidents where the family has verbally abused the nursing staff for consenting to the patient's wishes. You decide to convene the ethics committee. Discuss this in a paper of 3–4 pages, including the following:

· Using the ethical decision-making frameworks of your choice, how will you lead this committee?

· Who would you include in the committee?

Review the following resources for more information:

· Ethical Decision Making Resource 1

· Ethical Decision Making Resource 2: Click on the Making Ethical Decisions PDF on this ACHE ethics resource page.

· Ethical Decision Making Resource 3

References

American College of Healthcare Executives. (2017). About ACHE: Ethics toolkit. Retrieved from http://www.ache.org/abt_ache/EthicsToolkit/ethicsTOC.cfm

Bonde, S., & Firenze. P. (2013, May). A framework for making ethical decisions. Retrieved from https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions

Santa Clara University. (2015, August 1). A framework for ethical decision making. Retrieved from https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/a-framework-for-ethical-decision-making/

Please submit your assignment.

Ethical Decision Making Resource 1:

A Framework for Ethical Decision Making

This document is designed as an introduction to thinking ethically. It is also available as an app .

We all have an image of our better selves -- of how we are when we act ethically or are "at our best." We probably also have an image of what an ethical community, an ethical business, an ethical government, or an ethical society should be. Ethics really has to do with all these levels -- acting ethically as individuals, creating ethical organizations and governments, and making our society as a whole ethical in the way it treats everyone.

What is Ethics?

Simply stated, ethics refers to standards of behavior that tell us how human beings ought to act in the many situations in which they find themselves-as friends, parents, children, citizens, businesspeople, teachers, professionals, and so on.

It is helpful to identify what ethics is NOT:

· Ethics is not the same as feelings. Feelings provide important information for our ethical choices. Some people have highly developed habits that make them feel bad when they do something wrong, but many people feel good even though they are doing something wrong. And often our feelings will tell us it is uncomfortable to do the right thing if it is hard.

· Ethics is not religion. Many people are not religious, but ethics applies to everyone. Most religions do advocate high ethical standards but sometimes do not address all the types of problems we face.

· Ethics is not following the law. A good system of law does incorporate many ethical standards, but law can deviate from what is ethical. Law can become ethically corrupt, as some totalitarian regimes have made it. Law can be a function of power alone and designed to serve the interests of narrow groups. Law may have a difficult time designing or enforcing standards in some important areas, and may be slow to address new problems.

· Ethics is not following culturally accepted norms. Some cultures are quite ethical, but others become corrupt -or blind to certain ethical concerns (as the United States was to slavery before the Civil War). "When in Rome, do as the Romans do" is not a satisfactory ethical standard.

· Ethics is not science. Social and natural science can provide important data to help us make better ethical choices. But science alone does not tell us what we ought to do. Science may provide an explanation for what humans are like. But ethics provides reasons for how humans ought to act. And just because something is scientifically or technologically possible, it may not be ethical to do it.

Why Identifying Ethical Standards is Hard

There are two fundamental problems in identifying the ethical standards we are to follow:

1. On what do we base our ethical standards?

2. How do those standards get applied to specific situations we face?

If our ethics are not based on feelings, religion, law, accepted social practice, or science, what are they based on? Many philosophers and ethicists have helped us answer this critical question. They have suggested at least five different sources of ethical standards we should use.

Five Sources of Ethical Standards

The Utilitarian Approach Some ethicists emphasize that the ethical action is the one that provides the most good or does the least harm, or, to put it another way, produces the greatest balance of good over harm. The ethical corporate action, then, is the one that produces the greatest good and does the least harm for all who are affected -- customers, employees, shareholders, the community, and the environment. Ethical warfare balances the good achieved in ending terrorism with the harm done to all parties through death, injuries, and destruction. The utilitarian approach deals with consequences; it tries both to increase the good done and to reduce the harm done.

The Rights Approach Other philosophers and ethicists suggest that the ethical action is the one that best protects and respects the moral rights of those affected. This approach starts from the belief that humans have a dignity based on their human nature per se or on their ability to choose freely what they do with their lives. On the basis of such dignity, they have a right to be treated as ends and not merely as means to other ends. The list of moral rights -- including the rights to make one's own choices about what kind of life to lead, to be told the truth, not to be injured, to a degree of privacy, and so on -- is widely debated; some now argue that non-humans have rights, too. Also, it is often said that rights imply duties -- in particular, the duty to respect others' rights.

The Fairness or Justice Approach Aristotle and other Greek philosophers have contributed the idea that all equals should be treated equally. Today we use this idea to say that ethical actions treat all human beings equally-or if unequally, then fairly based on some standard that is defensible. We pay people more based on their harder work or the greater amount that they contribute to an organization, and say that is fair. But there is a debate over CEO salaries that are hundreds of times larger than the pay of others; many ask whether the huge disparity is based on a defensible standard or whether it is the result of an imbalance of power and hence is unfair.

The Common Good Approach The Greek philosophers have also contributed the notion that life in community is a good in itself and our actions should contribute to that life. This approach suggests that the interlocking relationships of society are the basis of ethical reasoning and that respect and compassion for all others -- especially the vulnerable -- are requirements of such reasoning. This approach also calls attention to the common conditions that are important to the welfare of everyone. This may be a system of laws, effective police and fire departments, health care, a public educational system, or even public recreational areas.

The Virtue Approach A very ancient approach to ethics is that ethical actions ought to be consistent with certain ideal virtues that provide for the full development of our humanity. These virtues are dispositions and habits that enable us to act according to the highest potential of our character and on behalf of values like truth and beauty. Honesty, courage, compassion, generosity, tolerance, love, fidelity, integrity, fairness, self-control, and prudence are all examples of virtues. Virtue ethics asks of any action, "What kind of person will I become if I do this?" or "Is this action consistent with my acting at my best?"

Putting the Approaches Together

Each of the approaches helps us determine what standards of behavior can be considered ethical. There are still problems to be solved, however.

The first problem is that we may not agree on the content of some of these specific approaches. We may not all agree to the same set of human and civil rights.

We may not agree on what constitutes the common good. We may not even agree on what is a good and what is a harm.

The second problem is that the different approaches may not all answer the question "What is ethical?" in the same way. Nonetheless, each approach gives us important information with which to determine what is ethical in a particular circumstance. And much more often than not, the different approaches do lead to similar answers.

Making Decisions

The more novel and difficult the ethical choice we face, the more we need to rely on discussion and dialogue with others about the dilemma. Only by careful exploration of the problem, aided by the insights and different perspectives of others, can we make good ethical choices in such situations.

We have found the following framework for ethical decision making a useful method for exploring ethical dilemmas and identifying ethical courses of action.

A Framework for Ethical Decision Making

Recognize an Ethical Issue

1. Could this decision or situation be damaging to someone or to some group? Does this decision involve a choice between a good and bad alternative, or perhaps between two "goods" or between two "bads"?

2. Is this issue about more than what is legal or what is most efficient? If so, how?

Get the Facts

3. What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision?

4. What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?

5. What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

Evaluate Alternative Actions

6. Evaluate the options by asking the following questions:

· Which option will produce the most good and do the least harm? (The Utilitarian Approach)

· Which option best respects the rights of all who have a stake? (The Rights Approach)

· Which option treats people equally or proportionately? (The Justice Approach)

· Which option best serves the community as a whole, not just some members? (The Common Good Approach)

· Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

7. Considering all these approaches, which option best addresses the situation?

8. If I told someone I respect -- or told a television audience -- which option I have chosen, what would they say?

Act and Reflect on the Outcome

9. How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?

10. How did my decision turn out and what have I learned from this specific situation?

This framework for thinking ethically is the product of dialogue and debate at the Markkula Center for Applied Ethics at Santa Clara University. Primary contributors include Manuel Velasquez, Dennis Moberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, David DeCosse, Claire André, and Kirk O. Hanson. It was last revised in May 2009.

Aug 1, 2015

Ethical Decision Making Resource 2:

Healthcare Management Ethics

No one would deny clinical and administrative healthcare professionals regularly encounter ethical challenges. For clinicians, the challenges may relate to a conflict regarding withholding or withdrawing life- sustaining interventions or breaching patient confidentiality. For the executive, the conflict may involve a decision concerning a needed service that is a financial drain on the organization or the abusive behavior of a highly productive administrator.

Ethical conflicts are best addressed when all the people who are legitimately involved have an opportunity to discuss their values, perceptions and concerns in an open and respectful environment.

What is the same for clinician and executive decision makers is the potential for an ethical conflict or controversy. All ethical conflicts are characterized by a number of common components. An ethical conflict occurs when an uncertainty, a question or a controversy arises regarding

competing ethical principles, personal values, or organizational and professional ethical standards of practice. Examples of such standards include the American College of Physicians’ Ethics Manual or the American College of Healthcare Executives’ Code of Ethics.

Once an ethical conflict is identified, the challenge becomes how healthcare leaders and other staff involved in the situation should respond. The use of a systematic process can enhance the analysis leading to a response that is ethically justifiable. For the clinician, executive or ethics committee member, applying a systematic process can diminish the possibility of making quick decisions lacking thoughtful reflection and sound ethical reasoning.

The Importance of a Standard Process for Resolution A little over a decade ago, I was changing positions. Because I talked frequently about the importance of systematic ethical reasoning, during a farewell gathering, I was given a small poster that hangs in my office today. It reads, “Ethics, schemethics; flip the damn coin.” The cynicism serves as a constant reminder of the need for the

opposite—to always apply a carefully developed process to address ethics conflicts. The process will take time and effort, yet it can lead to ethically defensible decisions rather than convey the general attitude, “Because I said so.” The process can foster a focused application of ethical principles, institutional values and policies to ethical conflicts. It promotes thoughtful and, hopefully, respectful dialogue between the parties involved in the ethical conflict.

Unlike some decision-making models, the application of a uniform systematic process for addressing both clinical and administrative issues is a subtle-but-important distinction. It emphasizes that a process should not be based on such a distinction, in no small part because the distinction between clinical and administrative issues can be fuzzy, leading to challenging questions regarding which process is the most appropriate to follow in any given ethics situation. Therefore, using one process to address either type of conflict has clear benefits.

In a July/August 2005 Healthcare Executive column, “An Organizational Ethics DecisionMaking Process,” I described a process for facilitating systematic ethical reasoning in response to an ethical conflict. I still adhere to the basic elements of that process; however, after teaching and applying the process in practice, I recognize the need for refinements.

The following is an updated decision-making process for making ethical decisions.

A six-step process should guide ethical decision making in healthcare.

Recognize the background (the circumstances leading to the ethics conflict). Identify all the relevant factors contributing to the ethical conflict. For a clinical case, it’s important to understand the medical issues involved, such as the patient’s diagnosis, prognosis, treatment options and goals of care. Additional key factors are the patient’s preferences; personal values; decision-making capacity; and, when the patient lacks that capacity, determination of the appropriate decision maker. Each individual with a stake in the decision—the patient, the patient’s family and staff members—should have an opportunity to express his or her perspectives regarding the various factors surrounding the ethical conflict. This discussion can take place during a group conference or in individual meetings. The importance of these discussions cannot be minimized to clarify the various perspectives. Additionally, understanding the relevant economic, policy, social and legal implications is essential. In this step, all the relevant factors from the perspective of all involved should be reviewed.

After identifying all the conflictrelated factors, situations may arise in which it becomes clear the perceived ethical conflict is really a disagreement about the facts of the case. In exploring the factors giving rise to a clinical ethics conflict, such as with the nurses, patient, family and physicians, it can become obvious there are different interpretations of the facts. For example, in an end-of-life-care situation, the family may have a different understanding of the patient’s prognosis than the physicians. This can be similar for organizational ethics situations. If the involved parties reach agreement concerning the facts, the ethical conflict may be diminished or even eliminated; however, in situations where the discussions reinforce that a conflict exists, the parties should move to the next step.

Identify the specific ethical question that need clarification. After determining all the facts, the various competing value perspectives and the contextual issues related to the ethical conflict, the next step is to specifically articulate the ethics conflict. Because these occur when competing values are at play, the ethical question should focus on identifying and agreeing on the competing values.

For example, are healthcare professionals morally obligated to provide an intervention requested by the patient they deem to be nonbeneficial—the conflict focuses on the underlying issue of whether patient autonomy should be limited in any way? Ethical questions should be identified and reviewed in such a way that consensus is reached among all the relevant parties. Failing to identify the specific ethical conflict(s) creates significant barriers to achieving a clear response to that conflict.

Consider the related ethical principles and/or organizational values. The next step is to acknowledge the relevant ethical principles and/or the organization’s values related to the ethical conflict. Do any particular organizational policies or, in some situations, legal perspectives, relate to the ethics question?

This step is an extension of the previous step—and in some situations, this step can be addressed at the same time as when the ethical question is identified. The precise order in this portion of the process is less important than ensuring that clear identification of the specific competing values is achieved.

Determine the options for response. In this step, the decision makers should recognize all the potential options for responding to the ethical question. This step includes reviewing the ethical justification for each option. What are the arguments for and against each option? Many people avoid this step or rarely look beyond the first suggested option. Such an approach can be attractive from a time perspective; however, it can lead to a decision lacking a critical analysis. Ethical decision making is more than following the steps in a quick, lock-step manner; it involves an appreciation for the complexity of each step and how each relates to the others.

Recommend a response. Following a thoughtful review of the various options and the ethical justification for each, decision makers should propose a response. One aspect for determining which option is morally justifiable is to assess the likely consequences of each option along with the underlying intention. This step is intended to prioritize the ethical principles or values related to each of the options. Ideally, consensus

should be reached around the recommended option.

Once a recommended option is selected, it should be shared with all involved parties. The ethical justification should be included in the recommended course of action. For a clinical ethics case, the recommendation should be noted in the patient’s chart or EHR.

Anticipate the ethical conflict. Unlike many decision-making models, this multiple-step process does not end with the resolution of the conflict response. I encourage this final step in the process—which, in some situations, may be the most challenging step in a systematic ethical-decision-making process.

Most ethical challenges focus not on isolated events, but on recurring issues. The presence of recurring ethical conflicts can undermine quality of care, staff morale, efficiency and productivity, operational costs and the organization’s culture. Due to the recurring nature and impact of ethical conflicts, clinical and/or administrative staff—with assistance from the ethics committee and quality improvement program—should pursue an inquiry to determine how future conflicts can be prevented. To do so requires a thorough exploration of two fundamental questions:

• Why did the ethical conflict occur? • What can be done to prevent the situation from recurring?

Exploring these questions can lead to a better understanding of how administrative and clinical leaders can develop

strategies for anticipating and preventing similar conflicts before they escalate. This approach, as described in “Preventing Ethics Conflicts and Improving Healthcare Quality Through System Redesign” (Nelson, W.A., et al., Quality and Safety in Health Care, 2010), features the application of methods and tools familiar to quality improvement. The process could lead to the development of ethics practice guidelines that can diminish the presence and impact of ethical conflicts throughout the organization.

Final Thoughts Because no healthcare decision is made in a vacuum, ethical conflicts are best addressed when all the people who are legitimately involved have an opportunity to discuss their values, perceptions and concerns in an open and respectful environment.

Depending on the situation, greater or lesser attention may be required for a particular step in the process; however, no step should be ignored. The process is not an algorithm providing one clear answer to every ethical conflict, but rather it is a method for understanding different perspectives on the conflict and enhancing ethical reasoning. Just as ethical reasoning is not limited to the purview of healthcare ethicists or ethics committee members, the process can be applied by any healthcare professional when confronted with an ethical conflict. s

William A. Nelson, PhD, HFACHE, is an associate professor at Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College. He also serves as adviser to the ACHE Ethics Committee ([email protected]).

William A. Nelson, PhD, HFACHE

Healthcare Executive JULY/AUG 2015

Ethical Decision Making Resource 3:

A Framework for Making Ethical Decisions

MAKING CHOICES: A FRAMEWORK FOR MAKING ETHICAL DECISIONS

Decisions about right and wrong permeate everyday life. Ethics should concern all levels of life: acting properly as individuals, creating responsible organizations and governments, and making our society as a whole more ethical. This document is designed as an introduction to making ethical decisions. It recognizes that decisions about “right” and “wrong” can be difficult, and may be related to individual context. It first provides a summary of the major sources for ethical thinking, and then presents a framework for decision-making.

1. WHAT IS ETHICS?:

Ethics provides a set of standards for behavior that helps us decide how we ought to act in a range of situations. In a sense, we can say that ethics is all about making choices, and about providing reasons why we should make these choices.

Ethics is sometimes conflated or confused with other ways of making choices, including religion, law or morality. Many religions promote ethical decision-making but do not always address the full range of ethical choices that we face. Religions may also advocate or prohibit certain behaviors which may not be considered the proper domain of ethics, such as dietary restrictions or sexual behaviors. A good system of law should be ethical, but the law establishes precedent in trying to dictate universal guidelines, and is thus not able to respond to individual contexts. Law may have a difficult time designing or enforcing standards in some important areas, and may be slow to address new problems. Both law and ethics deal with questions of how we should live together with others, but ethics is sometimes also thought to apply to how individuals act even when others are not involved. Finally, many people use the terms morality and ethics interchangeably. Others reserve morality for the state of virtue while seeing ethics as a code that enables morality. Another way to think about the relationship between ethics and morality is to see ethics as providing a rational basis for morality, that is, ethics provides good reasons for why something is moral.

2. TRADITIONAL ARRANGEMENT OF THE FIELD OF ETHICS:

There are many systems of ethics, and numerous ways to think about right and wrong actions or good and bad character. The field of ethics is traditionally divided into three areas: 1.) meta-ethics, which deals with the nature of the right or the good, as well as the nature and justification of ethical claims; 2.) normative ethics, which deals with the standards and principles used to determine whether something is right or good; 3.) applied ethics, which deals with the actual application of ethical principles to a particular situation. While it is helpful to approach the field of ethics in this order, we might keep in mind that this somewhat “top down” approach does not exhaust the study of ethics. Our experience with applying particular ethical standards or principles can inform our understanding of how good these standard or principles are.

Three Broad Types of Ethical Theory: Ethical theories are often broadly divided into three types: i) Consequentialist theories, which are primarily concerned with the ethical consequences of particular actions; ii) Non-consequentialist theories, which tend to be broadly concerned with the intentions of the person making ethical decisions about particular actions; and iii) Agent-centered theories, which, unlike consequentialist and non-consequentialist theories, are more concerned with the overall ethical status of individuals, or agents, and are less concerned to identify the morality of particular actions. Each of these three broad categories contains varieties of approaches to ethics, some of which share characteristics across the categories. Below is a sample of some of the most important and useful of these ethical approaches. i.) Consequentialist Theories:

The Utilitarian Approach Utilitarianism can be traced back to the school of the Ancient Greek philosopher Epicurus of Samos (341-270 BCE), who argued that the best life is one that produces the least pain and distress. The 18th Century British philosopher Jeremy Bentham (1748-1832) applied a similar standard to individual actions, and created a system in which actions could be described as good or bad depending upon the amount and degree of pleasure and/or pain they would produce. Bentham’s student, John Stuart Mill (1806-1873) modified this system by making its standard for the good the more subjective concept of “happiness,” as opposed to the more materialist idea of “pleasure.”

Utilitarianism is one of the most common approaches to making ethical decisions, especially decisions with consequences that concern large groups of people, in part because it instructs us to weigh the different amounts of good and bad that will be produced by our action. This conforms to our feeling that some good and some bad will necessarily be the result of our action and that the best action will be that which provides the most good or does the least harm, or, to put it another way, produces the greatest balance of good over harm. Ethical environmental action, then, is the one that produces the greatest good and does the least harm for all who are affected—government, corporations, the community, and the environment.

The Egoistic Approach One variation of the utilitarian approach is known as ethical egoism, or the ethics of self- interest. In this approach, an individual often uses utilitarian calculation to produce the greatest amount of good for him or herself. Ancient Greek Sophists like Thrasymacus (c. 459-400 BCE), who famously claimed that might makes right, and early modern thinkers like Thomas Hobbes (1588-1679) may be considered forerunners of this approach. One of the most influential recent proponents of ethical egoism was the Russian-American philosopher Ayn Rand (1905-1982), who, in the book The Virtue of Selfishness (1964), argues that self-interest is a prerequisite to self-respect and to respect for others. There are numerous parallels between ethical egoism and laissez-faire economic theories, in which the pursuit of self-interest is seen as leading to the benefit of society, although the benefit of society is seen only as the fortunate byproduct of following individual self-interest, not its goal.

The Common Good Approach The ancient Greek philosophers Plato (427-347 BCE) and Aristotle (384-322 BCE) promoted the perspective that our actions should contribute to ethical communal life life. The most influential modern proponent of this approach was the French philosopher Jean-Jacques Rousseau (1712-1778), who argued that the best society should be guided by the “general will” of the people which would then produce what is best for the people as a whole. This approach to ethics underscores the networked aspects of society and emphasizes respect and compassion for others, especially those who are more vulnerable.

ii.) Non-consequentialist Theories:

The Duty-Based Approach The duty-based approach, sometimes called deontological ethics, is most commonly associated with the philosopher Immanuel Kant (1724-1804), although it had important precursors in earlier non-consquentialist, often explicitly religious, thinking of people like Saint Augustine of Hippo (354-430), who emphasized the importance of the personal will and intention (and of the omnipotent God who sees this interior mental state) to ethical decision making. Kant argued that doing what is right is not about the consequences of our actions (something over which we ultimately have no control) but about having the proper intention in performing the action. The ethical action is one taken from duty, that is, it is done precisely because it is our obligation to perform the action. Ethical obligations are the same for all rational creatures (they are universal), and knowledge of what these obligations entail is arrived at by discovering rules of behavior that are not contradicted by reason.

Kant’s famous formula for discovering our ethical duty is known as the “categorical imperative.” It has a number of different versions, but Kant believed they all amounted to the same imperative. The most basic form of the imperative is: “Act only according to that maxim by which you can at the same time will that it should become a universal law.” So, for example, lying is unethical because we could not universalize a maxim that said “One should always lie.” Such a maxim would render all speech meaningless. We can, however, universalize the maxim, “Always speak truthfully,” without running into a logical contradiction. (Notice the duty-based approach says nothing about how easy or difficult it would be to carry out these maxims, only that it is our duty as rational creatures to do so.) In acting according to a law that we have discovered to be rational according to our own universal reason, we are acting autonomously (in a self-regulating fashion), and thus are bound by duty, a duty we have given ourselves as rational creatures. We thus freely choose (we will) to bind ourselves to the moral law. For Kant, choosing to obey the universal moral law is the very nature of acting ethically.

The Rights Approach The Rights approach to ethics is another non-consequentialist approach which derives much of its current force from Kantian duty-based ethics, although it also has a history that dates back at least to the Stoics of Ancient Greece and Rome, and has another influential current which flows from work of the British empiricist philosopher John Locke (1632-1704). This approach stipulates that the best ethical action is that which protects the ethical rights of those who are affected by the action. It emphasizes the belief that all humans have a right to dignity. This is based on a formulation of Kant’s categorical imperative that says: “Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means to an end.” The list of ethical rights is debated; many now argue that animals and other non-humans such as robots also have rights.

The Fairness or Justice Approach The Law Code of Hammurabi in Ancient Mesopotamia (c. 1750 BCE) held that all free men should be treated alike, just as all slaves should be treated alike. When combined with the universality of the rights approach, the justice approach can be applied to all human persons. The most influential version of this approach today is found in the work of American philosopher John Rawls (1921-2002), who argued, along Kantian lines, that just ethical principles are those that would be chosen by free and rational people in an initial situation of equality. This hypothetical contract is considered fair or just because it provides a procedure for what counts as a fair action, and does not concern itself with the consequences of those actions. Fairness of starting point is the principle for what is considered just.

The Divine Command Approach As its name suggests, this approach sees what is right as the same as what God commands, and ethical standards are the creation of God’s will. Following God’s will is seen as the very definition what is ethical. Because God is seen as omnipotent and possessed of free will, God could change what is now considered ethical, and God is not bound by any standard of right or wrong short of logical contradiction. The Medieval Christian philosopher William of Ockham (1285-1349) was one of the most influential thinkers in this tradition, and his writings served as a guide for Protestant Reformers like Martin Luther (1483-1546) and Jean Calvin (1509-1564). The Danish philosopher Søren Kierkegaard (1813-1855), in praising the biblical Patriarch Abraham’s willingness to kill his son Isaac at God’s command, claimed that truly right action must ultimately go beyond everyday morality to what he called the “teleological suspension of the ethical,” again demonstrating the somewhat tenuous relationship between religion and ethics mentioned earlier. iii.) Agent-centered Theories:

The Virtue Approach One long-standing ethical principle argues that ethical actions should be consistent with ideal human virtues. Aristotle, for example, argued that ethics should be concerned with the whole of a person’s life, not with the individual discrete actions a person may perform in any given situation. A person of good character would be one who has attainted certain virtues. This approach is also prominent in non-Western contexts, especially in East Asia, where the tradition of the Chinese sage Confucius (551-479 BCE) emphasizes the importance of acting virtuously (in an appropriate manner) in a variety of situations. Because virtue ethics is concerned with the entirety of a person’s life, it takes the process of education and training seriously, and emphasizes the importance of role models to our understanding of how to engage in ethical deliberation.

The Feminist Approach In recent decades, the virtue approach to ethics has been supplemented and sometimes significantly revised by thinkers in the feminist tradition, who often emphasize the importance of the experiences of women and other marginalized groups to ethical deliberation. Among the most important contributions of this approach is its foregrounding of the principle of care as a legitimately primary ethical concern, often in opposition to the seemingly cold and impersonal justice approach. Like virtue ethics, feminist ethics concerned with the totality of human life and how this life comes to influence the way we make ethical decisions.

Applied Ethics Terms Used in Ethical Judgments Applied ethics deals with issues in private or public life that are matters for ethical judgments. The following are important terms used in making moral judgments about particular actions.

Obligatory: When we say something is ethically “obligatory” we mean that it is not only right to do it, but that it is wrong not to do it. In other words, we have a ethical obligation to perform the action. Sometimes the easiest way to see if an action is ethically obligatory is to look at what it would mean NOT to perform the action. For example, we might say it is ethically obligatory for parents to care for their children, not only because it is right for them to do it, but also because it is wrong for them not to do it. The children would suffer and die if parents did not care for them. The parents are thus ethically “obligated” to care for their children.

Impermissible: The opposite of an ethically obligatory action is an action that is ethically impermissible, meaning that it is wrong to do it and right not to do it. For example, we would say that murder is ethically impermissible.

Permissible: Sometimes actions are referred to as ethically permissible, or ethically “neutral,” because it is neither right nor wrong to do them or not to do them. We might say that having plastic surgery is ethically permissible, because it is not wrong to have the surgery (it is not impermissible), but neither is it ethically necessary (obligatory) to have the surgery. Some argue that suicide is permissible in certain circumstances. That is, a person would not be wrong in committing suicide, nor would they be wrong in not committing suicide. Others would say that suicide is ethically impermissible.

Supererogatory: A fourth type of ethical action is called supererogatory. These types of actions are seen as going “above and beyond the call of duty.” They are right to do, but it is not wrong not to do them. For example, two people are walking down a hallway and see a third person drop their book bag, spilling all of their books and papers onto the floor. If one person stops to help the third person pick up their books, but the other person keeps on walking, we somehow feel that the person who stopped to help has acted in a more ethically appropriate way than the person who did not stop, but we cannot say that the person who did not stop was unethical in not stopping. In other words, the person who did not help was in no way obligated (it was not ethically obligatory) to help. But we nevertheless want to ethically praise the person who did stop, so we call his or her actions supererogatory.

3. FRAMEWORKS FOR ETHICAL DECISION-MAKING:

Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced method for exploring the ethical aspects of a decision and weighing the considerations that should impact our choice of a course of action. Having a method for ethical decision making is essential. When practiced regularly, the method becomes so familiar that we work through it automatically without consulting the specific steps. This is one reason why we can sometimes say that we have a “moral intuition” about a certain situation, even when we have not consciously thought through the issue. We are practiced at making ethical judgments, just as we can be practiced at playing the piano, and can sit and play well “without thinking.” Nevertheless, it is not always advisable to follow our immediate intuitions, especially in particularly complicated or unfamiliar situations. Here our method for ethical decision making should enable us to recognize these new and unfamiliar situations and to act accordingly. The more novel and difficult the ethical choice we face, the more we need to rely on discussion and dialogue with others about the dilemma. Only by careful exploration of the problem, aided by the insights and different perspectives of others, can we make good ethical choices in such situations.

Three Frameworks Based upon the three-part division of traditional normative ethical theories discussed above, it makes sense to suggest three broad frameworks to guide ethical decision making: The Consequentialist Framework; The Duty Framework; and the Virtue Framework.

While each of the three frameworks is useful for making ethical decisions, none is perfect—otherwise the perfect theory would have driven the other imperfect theories from the field long ago. Knowing the advantages and disadvantages of the frameworks will be helpful in deciding which is most useful in approach the particular situation with which we are presented.

The Consequentialist Framework In the Consequentialist framework, we focus on the future effects of the possible courses of action, considering the people who will be directly or indirectly affected. We ask about what outcomes are desirable in a given situation, and consider ethical conduct to be whatever will achieve the best consequences. The person using the Consequences framework desires to produce the most good.

Among the advantages of this ethical framework is that focusing on the results of an action is a pragmatic approach. It helps in situations involving many people, some of whom may benefit from the action, while others may not. On the other hand, it is not always possible to predict the consequences of an action, so some actions that are expected to produce good consequences might actually end up harming people. Additionally, people sometimes react negatively to the use of compromise which is an inherent part of this approach, and they recoil from the implication that the end justifies the means. It also does not include a pronouncement that certain things are always wrong, as even the most heinous actions may result in a good outcome for some people, and this framework allows for these actions to then be ethical.

The Duty Framework In the Duty framework, we focus on the duties and obligations that we have in a given situation, and consider what ethical obligations we have and what things we should never do. Ethical conduct is defined by doing one’s duties and doing the right thing, and the goal is performing the correct action.

This framework has the advantage of creating a system of rules that has consistent expectations of all people; if an action is ethically correct or a duty is required, it would apply to every person in a given situation. This even-handedness encourages treating everyone with equal dignity and respect.

This framework also focuses on following moral rules or duty regardless of outcome, so it allows for the possibility that one might have acted ethically, even if there is a bad result. Therefore, this framework works best in situations where there is a sense of obligation or in those in which we need to consider why duty or obligation mandates or forbids certain courses of action.

However, this framework also has its limitations. First, it can appear cold and impersonal, in that it might require actions which are known to produce harms, even though they are strictly in keeping with a particular moral rule. It also does not provide a way to determine which duty we should follow if we are presented with a situation in which two or more duties conflict. It can also be rigid in applying the notion of duty to everyone regardless of personal situation.

The Virtue Framework In the Virtue framework, we try to identify the character traits (either positive or negative) that might motivate us in a given situation. We are concerned with what kind of person we should be and what our actions indicate about our character. We define ethical behavior as whatever a virtuous person would do in the situation, and we seek to develop similar virtues.

Obviously, this framework is useful in situations that ask what sort of person one should be. As a way of making sense of the world, it allows for a wide range of behaviors to be called ethical, as there might be many different types of good character and many paths to developing it. Consequently, it takes into account all parts of human experience and their role in ethical deliberation, as it believes that all of one’s experiences, emotions, and thoughts can influence the development of one’s character.

Although this framework takes into account a variety of human experience, it also makes it more difficult to resolve disputes, as there can often be more disagreement about virtuous traits than ethical actions. Also, because the framework looks at character, it is not particularly good at helping someone to decide what actions to take in a given situation or determine the rules that would guide one’s actions. Also, because it emphasizes the importance of role models and education to ethical behavior, it can sometimes merely reinforce current cultural norms as the standard of ethical behavior.

Putting the Frameworks Together By framing the situation or choice you are facing in one of the ways presented above, specific features will be brought into focus more clearly. However, it should be noted that each framework has its limits: by focusing our attention on one set of features, other important features may be obscured. Hence it is important to be familiar with all three frameworks and to understand how they relate to each other—where they may overlap, and where they may differ.

The chart below is designed to highlight the main contrasts between the three frameworks:

	Consequentialist	Duty	Virtue
Deliberative process	What kind of outcomes should I produce (or try to produce)?	What are my obligations in this situation, and what are the things I should never do?	What kind of person should I be (or try to be), and what will my actions show about my character?
Focus	Directs attention to the future effects of an action, for all people who will be directly or indirectly affected by the action.	Directs attention to the duties that exist prior to the situation and determines obligations.	Attempts to discern character traits (virtues and vices) that are, or could be, motivating the people involved in the situation.
Definition of Ethical Conduct	Ethical conduct is the action that will achieve the best consequences.	Ethical conduct involves always doing the right thing: never failing to do one's duty.	Ethical conduct is whatever a fully virtuous person would do in the circumstances.
Motivation	Aim is to produce the most good.	Aim is to perform the right action.	Aim is to develop one’s character.

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Because the answers to the three main types of ethical questions asked by each framework are not mutually exclusive, each framework can be used to make at least some progress in answering the questions posed by the other two.

In many situations, all three frameworks will result in the same—or at least very similar—conclusions about what you should do, although they will typically give different reasons for reaching those conclusions.

However, because they focus on different ethical features, the conclusions reached through one framework will occasionally differ from the conclusions reached through one (or both) of the others.

4. APPLYING THE FRAMEWORKS TO CASES:

When using the frameworks to make ethical judgments about specific cases, it will be useful to follow the process below.

Recognizing an Ethical Issue One of the most important things to do at the beginning of ethical deliberation is to locate, to the extent possible, the specifically ethical aspects of the issue at hand. Sometimes what appears to be an ethical dispute is really a dispute about facts or concepts. For example, some Utilitarians might argue that the death penalty is ethical because it deters crime and thus produces the greatest amount of good with the least harm. Other Utilitarians, however, might argue that the death penalty does not deter crime, and thus produces more harm than good. The argument here is over which facts argue for the morality of a particular action, not simply over the morality of particular principles. All Utilitarians would abide by the principle of producing the most good with the least harm.

Consider the Parties Involved Another important aspect to reflect upon are the various individuals and groups who may be affected by your decision. Consider who might be harmed or who might benefit.

Gather all of the Relevant Information Before taking action, it is a good idea to make sure that you have gathered all of the pertinent information, and that all potential sources of information have been consulted.

Formulate Actions and Consider Alternatives Evaluate your decision-making options by asking the following questions:

Which action will produce the most good and do the least harm? (The Utilitarian Approach) Which action respects the rights of all who have a stake in the decision? (The Rights Approach)

Which action treats people equally or proportionately? (The Justice Approach)

Which action serves the community as a whole, not just some members? (The Common Good Approach)

Which action leads me to act as the sort of person I should be? (The Virtue Approach)

Make a Decision and Consider It After examining all of the potential actions, which best addresses the situation? How do I feel about my choice?

Act Many ethical situations are uncomfortable because we can never have all of the information. Even so, we must often take action.

Reflect on the Outcome What were the results of my decision? What were the intended and unintended consequences? Would I change anything now that I have seen the consequences?

5. CONCLUSIONS:

Making ethical decisions requires sensitivity to the ethical implications of problems and situations. It also requires practice. Having a framework for ethical decision making is essential. We hope that the information above is helpful in developing your own experience in making choices.

Acknowledgements:

This framework for thinking ethically is the product of dialogue and debate in the seminar Making Choices: Ethical Decisions at the Frontier of Global Science held at Brown University in the spring semester 2011. It relies on the Ethical Framework developed at the Markkula Center for Applied Ethics at Santa Clara University and the Ethical Framework developed by the Center for Ethical Deliberation at the University of Northern Colorado as well as the Ethical Frameworks for Academic Decision-Making on the Faculty Focus website which in turn relies upon Understanding Ethical Frameworks for E-Learning Decision-Making, December 1, 2008, Distance Education Report (find url)

Primary contributors include Sheila Bonde and Paul Firenze, with critical input from James Green, Margot Grinberg, Josephine Korijn, Emily Levoy, Alysha Naik, Laura Ucik and Liza Weisberg. It was last revised in May, 2013.