Rae, Moral Choices: Ch4 - Making ethical decisions

Scott Rae Moral ChoicesThursday 17 May 2012

MAKING ETHICAL DECISIONS Chapter 4Thursday 17 May 2012

A model for making moral decisions Rae suggests the following procedure for making moral decisions - within this his work is not to get you to the “right” answer but to help you ask the right questions in your ethical deliberation. Rae says his model is free from cultural, ethnic and religious background biases - though it is consistent with the bible and uses biblical principles, it is not a distinctively “Christian model”.Thursday 17 May 2012

A model for making moral decisions It is oriented towards virtues and principles with consideration of consequences as a supporting role. Many moral dilemmas or issues are not addressed clearly, if at all, in the Bible. So we apply principles and virtues to each - the problem then becomes which to apply and how. Often weighting needs to be given to elements within a problem. There is a danger of trying to oversimplify things by claiming to be biblical.Thursday 17 May 2012

What is an ethical dilemma? (How would I know if I were facing one?) An ethical dilemma is a conﬂict between two or more value - or virtue driven interests. You have to identify the parties in the conﬂict, what their interests are, and what virtues and values underlie those interests. There follows Rae’s list of elements for making moral decisions:Thursday 17 May 2012

1. Gather the facts The simplest way of clarifying an ethical dilemma is to make sure the facts are clear. Ask: Do you have all the facts that are necessary to make a good decision? What do we know? What do we need to know? In this light it might become clear that the dilemma is not ethical but about communication or strategy.Thursday 17 May 2012

2. Determine the ethical issues Ethical interests are stated in terms of legitimate competing interests or goods. The competing interests are what creates the dilemma. Moral values and virtues must support the competing interests in order for an ethical dilemma to exist. If you cannot identify the underlying values/virtues then you do not have an ethical dilemma. Often people hold these positions strongly and with passion because of the value / virtue beneath them.Thursday 17 May 2012

3. Determine what virtues / principles have a bearing on the case In an ethical dilemma certain values and principles are central to the competing positions. Identify these. Determine if some should be given more weight than others. Ask what the source for the principle is - constitution, culture, natural law, religious tradition... These supplement biblical principles.Thursday 17 May 2012

4. List the alternatives Creatively determine possible courses of action for your dilemma. Some will almost immediately be discarded but generally the more you list the greater potential for coming up with a really good one. It will also help you come up with a broader selection of ideas.Thursday 17 May 2012

5. Compare the alternatives with the virtues / principles This step eliminates alternatives as they are weighed by the moral principles which have a bearing on the case. Potentially the issue will be resolved here as all alternatives except one are eliminated. Here you must satisfy all the relevant virtues and values - so at least some of the alternatives will be eliminated (even if you still have to go on to step 6). Often here you have to weight principles and virtues - make sure you have a good reason for each weightingThursday 17 May 2012

6. Consider the consequences If principles have not yielded a clear decision consider the consequences of your alternatives. Take the alternatives and work out the positive and negative consequences of each. Estimate how beneﬁcial each +ve and -ve consequence is - some might have greater weight than others.Thursday 17 May 2012

7. Make a decision Ethical decisions rarely have pain-free solutions - it might be you have to choose the solution with the least number of problems / painful consequences. Even when making a “good” decision you might still lose sleep over it!Thursday 17 May 2012

Applying the model: A case study This has been adapted from Rae’s original. It is about medical ethics. - 67 year old Indian woman diagnosed with a form of cancer which is usually treated by chemotherapy. - at admission she is fully competent and able to make her own decisions - she knows something is wrong with her and appears fearful and anxious about what getting well might involve.Thursday 17 May 2012

- she lives with her son and his wife - the family appear happy - the son has taken responsibility for her as her husband has died - the son translates for her with almost all information needing translating - the son does not want her to know anything more than the bare minimum about the treatment as he fears she will give up on life and resign herself to dying - the son is strongly motivated by cultural and family valuesThursday 17 May 2012

- The patient does not know her full diagnosis or the full eﬀects of the chemotherapy - she knows she is sick and treatment will make her feel sick to her stomach as well as losing her hair You are the doctor - what would you do? Follow the family’s wishes (based on their culture)? Decide the patient needs to know what is happening - tell her even if it increases her fear (and alienates you from the family)Thursday 17 May 2012

1. Gather the facts - go back over the information given and write down all the facts. 2. Determine ethical issues - patient autonomy, including giving consent for treatment versus what a caring family think is best for the patient. In such a situation nurses are bound by what the doctor decides - yet still they have to solve the problem of obedience to the doctor with the patients integrity in being able to give informed consent.Thursday 17 May 2012

3. Determine what values / principles have a bearing on the case - the right of the patient to give informed consent - chemotherapy is a very invasive treatment. This is recognised by law, the person has a right to control what happens to their body. Such dignity comes from being made in the image of God.Thursday 17 May 2012

- the obligation of the medical team to act in the patients best interest. They should do good for the patient whenever they can - to act with compassion (the family will also claim to be acting in compassion)Thursday 17 May 2012

- respect for the family’s wishes and culture. Humility is the virtue which says the doctors must realise not all they think is best. How heavily do they respect family / cultural values? The family may think they are taking some of the burden for their mother by making the decisions and not telling her everything - this caring is highly valued by them - also the law regarding informed consent must be applied, and nursing staﬀs obedience to doctorsThursday 17 May 2012

4. List the alternatives - attempt to convince the family of the seriousness of the treatment and why she needs to know - call an ethics committee conference to discus the case and try to convince the family to tell her These two options should be discussed prior to any further treatment. - override the family’s wishes and tell the patient of her condition and the treatmentThursday 17 May 2012

- continue to follow the family’s wishes, the son continues to translate and she knows nothing more - wait for the patient to ask questions about treatment and then encourage her to ask very direct questions of her family and doctor (another translator is required here) - bring in another translator and ask the woman if she wants to know the details of all that is happening - likely to cause cultural oﬀense to the sonThursday 17 May 2012

5. Compare the alternatives with the virtues / principles - initially try to pursue all possibilities of talking with the family and the doctors trying to get them to disclose the information themselves - if above is unsuccessful you can either withhold or disclose information to the patient - use another translator and tell the patient (or ask if she wants to know full details of what is going on - this alternative respects her autonomy)Thursday 17 May 2012

- she can make it clear at this time she wants her son to make the decisions for her - this would satisfy most important principles / virtues - if she chooses to know then it is her who is challenging the culture, yet she retains her dignity and has full information - if nurses are unhappy with what is happening the most viable option is probably for them to be requested to be removed from the caseThursday 17 May 2012

6. Consider the consequences If you disclose the information directly possible consequences include; - family feel alienated, cultural values have been violated - family may take patient to another hospital - patient may “give up” - patient might be happy they are ﬁnally being told the truthThursday 17 May 2012

If you continue withholding information possible consequences include; - patient continues to be fearful and anxious about the treatment - patient ﬁnds out somehow and trust is compromised - family are happy cultural values are being respectedThursday 17 May 2012

If you ask the patient if she wants to know through another translator, possible consequences include; - family are unhappy at disrespect for their cultural values - patient gets to speak for herself and make own decisions - she can choose to let her son continue making the decisions, both law and culture are satisﬁed here - patient will be relieved as she knows her wishes have been respectedThursday 17 May 2012

7. Make a decision - we have had to think through our ideas of respect for family and culture - how far should we go in respecting this cultural approach, is the patients best interest compromised, is her dignity as an individual respected? Rae suggests, “Here it seems the alternative that involves asking the patient if she wants to know the details of her situation satisﬁes most of the virtues and values at stake and produces the best balance of consequences too.”Thursday 17 May 2012

Rae, Moral Choices: Ch4 - Making ethical decisions

by Richard Chamberlain

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Rae, Moral Choices: Ch4 - Making ethical decisions Presentation Transcript