Running Head: ETHICAL DECISION MAKING: MORAL MODEL FRAMEWORK
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Ethical Decision Making Using Moral Model Framework
Name
Liberty University
ETHICAL DECISION MAKING: MORAL MODEL FRAMEWORK 2
Ethical Decision Making Using Moral Model Framework
Nursing is a noble profession and a career which is riddled with challenges of providing
care within parameters defined by ethical limits. While it is the duty of every nurse to provide
care which cause the least discomfort to patients, it is not without the challenge of ensuring the
balance between discomfort and what is medically necessary for optimal recovery of a patient’s
condition. At the center of providing patients with the most current evidence-based treatment
options, lies the inherent need to maintain patient’s autonomy to liberty and self-determination in
decision making regarding the type of treatment a patient receives (Guido, 2014). Therefore, the
purpose of this paper is to delineate the process of ethical decision making using the Moral
Model framework steps as exemplified by Guido (2014).
Ethical Dilemma
In today’s technologically complex healthcare system, there are numerous patients’ care
scenarios which raise ethical concerns in clinical practice. This calls for application of clinical
ethics when designing treatment modalities for such cases that pose ethical concerns and possible
ethical dilemma. According to Indian State Nurse Association (ISNA) bulletin, clinical ethics
does not provide a single point of reference, instead there are variety of potential “rights”
options, each of which “deserves to be explored with respect, consideration and thoughtfulness”
(What Do I Do Now? Ethical Dilemmas in Nursing and Health Care, 2013, p.7).;This is the
premise of using the Moral Model framework (Guido,2014) in ethical decision making to resolve
an ethical dilemma using the best available option that is acceptable first to patient, and also in
tandem to family members’ believes if any and the healthcare providers.
A case in consideration is that of a 22-year-old, single Hispanic female who was brought
to the emergency department for evaluation and treatment of a deep cut in her medial left thigh
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which was a result of self-mutilating behavior. Upon clinical evaluation patient had a history of
borderline personality disorder with significant history of cutting and self-mutilation behavior
from the age of 12. On assessment, the cut was moderately deep and the wound required sutures
to prevent infection and also promote healing. However, despite education by the healthcare
provider on the need to have the wound sutured, the patient adamantly declined the treatment
stating that she was fine, and that the pain from the wound was helping her deal with anxiety
which was the reason for the self-harm.
Patient was evaluated by psychiatric nurse practitioner for competency, and was found to
be of sound mind and able to make informed judgment and decision based on information
provided. Patient was further educated on the clinical ramification of declining treatment, but
still maintained her stand that she would not accept that mode of treatment. The mother who had
accompanied the patient to the emergence department was present, and concurred with
healthcare provider for the need to have the wound sutured due to the extent of the injury.
The ethical issues and dilemma in this case scenario is that by patient declining the
treatment which was clearly explained following clinical assessment, there was possibility that
the wound would become infected with high probability of developing sepsis. This could result
in further complication of treatment and possible death of the patient if not treated appropriately.
Another ethical dilemma is the healthcare provider’s worry that the consequences of wound
becoming infected may drive a desire to treat the wound irrespective of patient’s wishes, and this
can be seen as working in a paternalistic manner which would contravene patient’s right to
autonomy (Guido, 2014). The healthcare provider may also have struggled with the thought of
whether to infringe on patient’s right to autonomy by supporting the principle of beneficence,
which is to provide the good (Guido, 2014), which sometime may be used to impose treatment
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on patients whether they want it or not if the good outweighs the right to self-determination. This
presented a major ethical dilemma considering what was at stake if the wound was not sutured.
Options for resolution
Ethical dilemma may occur when there are multitude of alternative options (Foreman,
2011) when dealing with a given clinical situation which may create conflicting moral principles
which form the base of difficult ethical concerns. According to Weimand, Sällström, Hall-Lord,
and Hedelin (2013) nurses in mental health services caring for people who directly or indirectly
carry burdens related to mental illness faces complex situations when carrying out treatment in
this population. According to the authors, the nurse must be able to establish a trusting alliance
which forms the basis of therapeutic relationship. It is through this trusting alliance that the
patient is able to open up to treatment options. Putting patient first is key to establishing a
therapeutic relationship, which is a necessary recipe to trusting the treatment options provided by
the healthcare providers.
There are several options besides establishing a trusting alliance for the case scenario
which could be considered for resolution of ethical dilemma. One option would be to have a
different provider go through the education with the patient again, and provide a new forum for
patient to consider. The patient may have felt unsafe with the first provider, and this could have
been based on cultural background since the healthcare was a male treating a female of Hispanic
background. She may have had issues with privacy bearing in mind where the cut was in her
medial thigh and this could have raised issue with who was to do the sutures. Also, the mother
could have been given a chance to talk to the patient and try to convince her daughter on the
need for the proper treatment and explore why she was not willing to have her wound sutured.
There is possibility she could have listened and consider the option if the two were given a
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chance to talk privately. Even though the patient was cleared for competence by the psychiatric
nurse practitioner, another option was to involve a psychiatrist to do another psychiatric
evaluation at a different time while the patient was still undergoing first aid treatment and further
determine her competence. The mental status may have changed allowing application of
principle of paternalism. Finally, going by the wish of the patient is an option which may be
painful in the eyes of the healthcare providers and the family, but still a very valid option.
Best Option and Justification
Foreman (2011) reported that it is important to explore all the available and viable
options and pursue the most appropriate one after weighing all the factors surrounding the
options. Inggs and Christensen (2015) posited that “complex moral issues often arise within the
healthcare setting and it is fundamental that healthcare professional are able to manage
vulnerable patients and their family’s need ethically” (p.17). With this in mind, and after careful
consideration of all the available options, the best option which has the least ethical risk is to go
by the patient’s wish after exploring all available options, providing all alternatives to proposed
treatment, and disclosing all “the needed facts in understandable terms” (Guido, 2014, p.118).
These are the bases of informed consent and if the patient was deemed competent by the
psychiatrist and still maintained on not having sutures, then she has a right to “informed refusal”
(Guido, 2014, p.119) and this demands that she is fully explained of all the risks and
complications arising and still does not consent to the recommended treatment. This removes all
the ethical burden from the healthcare providers, allowing the patient right to autonomy and the
freedom to tailor their care outside the healthcare’s realm of practice.
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Hypothetical Application and Evaluation
When dealing with ethical problems which raise ethical dilemma, it is important to
examine the context of the circumstances which surround the specific nature of clinical issue,
and determine whether they are of ethical, medical or social or cultural origin in order to find the
best options. According to Inggs and Christensen (2015) arriving at the best option when ethical
dilemmas are involved require the healthcare providers to consider a decision-making framework
which consider several key ethical principles, such as right to autonomy, beneficence,
nonmaleficence, justice, and paternalism, and take into account all the factors surrounding these
principles as a base of solving an ethical dilemma. After taking the core principles of ethics into
account, it becomes easier to guide a patient into understanding his or her rights and the
treatment trajectory which best suit the patient without creating any ethical risk to healthcare
providers. This also forms the base for evaluation of care which is ethically sound when all
factors have been considered to arrive at the best option for a patient’s treatment modality.
Conclusion
The clinical decision that a nurse makes concerning the care of a patient’s needs should
be considered from an ethical base. There is a higher probability of producing better outcomes
under any given circumstance if any decision is made from the ethical viewpoint. This also
ensure that the healthcare providers are exonerated from any blame of negligence or unnecessary
paternalism which may form bases of ethical concerns with possible law suits.
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References
Foreman, T. (2011). Ethical dilemmas in the workplace.;Ontario Occupational Health Nurses
Association Journal,;30(3), 17-18.
Guido, G.W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ:
Pearson.
Inggs, R., & Christensen, M. (2015). To Feed or Not to Feed: Using an Ethical Decision Making
Model to Support Patient Choice.;Singapore Nursing Journal,;42(3), 17-21.
Weimand, B. M., Sällström, C., Hall-Lord, M., & Hedelin, B. (2013). Nurses’ dilemmas
concerning support of relatives in mental health care.;Nursing Ethics,;20(3), 285-299.
doi:10.1177/0969733012462053
What Do I Do Now? Ethical Dilemmas in Nursing and Health Care. (2013).;Indiana State
Nurses Association (ISNA) Bulletin,;39(2), 5-12.
