2. A Six-Step Process of Ethical Decision Making in Arriving
at a Caring Response
Ethical decision making requires a thoughtful reflection and logical
judgment.
• Following are six steps for reflecting on and analyzing the situation
while still acknowledging the intense emotions everyone may be
experiencing about the situation.
• Step 1: Get the Story Straight—Gather Relevant Information.
– The first step in informed decision making is to gather as much information as possible.
– Without knowing as much as possible about the story line, it is impossible to ascertain
the attitudes, values, and duties embedded in it.
– Gathering as much relevant information as possible sets the essential basis for
analysis and action consistent with arriving at a caring response.
• Step 2: Identify the Type of Ethical Problem.
– Moral Distress
– Ethical Dilemma
– Locus of Authority Problem
• An essential step in analysis is to identify the type or types of ethical problems that
you face
• Step 3: Use Ethics Theories or Approaches to Analyze the Problem(s)
1. Utilitarianism.
2. Deontology
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3. A Six-Step Process of Ethical Decision Making in Arriving
at a Caring Response
• Step 4: Explore the Practical Alternatives.
– To determine what can be done in the situation.
– May exercise own imagination and confer with colleagues regarding the
actual strategies and available options.
• Step 5: Complete the Action
– The goal of analysis is finally to act!
– Some decisions are literally life and death decisions; all are of deep
significance to the people facing the particular situation.
– this final step requires courage and the strength of will to go ahead, with the
knowledge that there may be risks.
• Step 6: Evaluate the Process and Outcome
– Pause and engage in a reflective examination of the situation. The practical goal
of ethics is to resolve ethical problems, thereby upholding important moral values
and duties.
• Critical reflection = clinical growth. Reflection on your action prepares you for
how you can continue to learn from your experience.
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4. Moral rights
These have such force as the accepted rules and consensus of the
moral community give them , may depend on available resources,
and often not enforceable.
Legal rights
These are enforceable through civil or criminal courts such as right
of privacy or freedom of assault, may imprisonment apply in
some case.
On what base we blame or praise people for actions:
• Knew what they were doing (not ignorant or insane) .
• If act voluntarily not compulsory
• If had other options not powerless to act otherwise.
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Patients’ Rights
5. • Patient rights are a subset of human rights.
• “Human rights” refers to minimum standards for the ways persons can
expect to be treated by others,
• Behind every ‘patient right’ is one or more ethical principle from which
that right is derived.
• Establishing clearly defined patient rights helps standardize care across
healthcare fields and enables patients to have uniform expectations during
their treatment.
• Modern bills of patient rights establish that persons can expect certain
treatment regardless of their socioeconomic status, religious affiliation,
gender, or ethnicity.
• Commonly established rights tend to derive from a core set of ethical
principles, including autonomy of the patient, beneficence, nonmaleficence,
(distributive) justice, patient-provider fiduciary (trusting) relationship, and
inviolability of human life.
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Patients’ Rights
6. Core Ethical Principles in Modern Medicine
Beneficence
• Beneficence is doing what is in the best interest of the patient throughout
the process of diagnosis and treatment.
Patient Autonomy
• Autonomy (literally “self-rule”) refers to the capacity to live
according to one's own reasons and motives.
• A patient who can defend his or her judgments has the right to
make decisions.
– A patient's autonomy is violated when family members or
members of a healthcare team pressure a patient or when they
act on the patient’s behalf without the patient’s permission (in a
non-emergency situation).
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7. Nonmaleficence (“Do no harm”)
• nonmaleficence seeks to ensure a patient will be no worse
off (physically, emotionally, or otherwise) after treatment
than before.
– Despite the potential reason why treatment is beneficial, the
therapy may have unintended harm.
Patient-Provider Fiduciary Relationship
– is the trust (Latin: fiducia) that the client places in the
professional. Primarily, the belief is that the health
care professional will act in such a way as to serve the client’s
best interests.
Justice
• All persons (patients) will be treated fairly and equitably.
• Not only respecting the rights of individuals but also treating all patients
in a given situation the same regardless of who they are.
Sanctity (holiness) and Dignity of Human Life
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Core Ethical Principles in Modern Medicine
8. Examples of patient rights
Informed Consent
• The right to informed consent is composed of two parts:
– first, the right to be informed of potential harm to one’s
property (one’s body) caused by a hired agent,
– second, the right to autonomy.
• a patient should be given an adequate amount of information to
understand his or her state of health
• informed consent is "a basic social policy" necessary to preserve
patient autonomy even at the expense of a healthcare provider’s
desire for beneficence.
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9. Refusal of Treatment (by both patient and
physician)
• A patient may refuse treatment that the healthcare provider thinks
to be an act of beneficence out of the principle of autonomy.
• a physician may refuse to offer a treatment out of nonmaleficence
because the physician believes the treatment would cause greater
harm than good.
• Either way, the medical professional must provide informed
consent regarding the issue when it is possible to do so.
Medical Treatment in an Emergency
• Life-saving measures must be taken to the point of stabilization,
regardless of the patient’s ability to pay for treatment.
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Examples of patient rights
10. Confidentiality
• The patient trusts that the health professional will not allow others
to know particulars of the patient’s illness or situation,
information that could be used by others to take advantage of or
otherwise harm the patient.
• By preservation of confidentiality, patients are granted autonomy
in that they retain control over who has access to know the status
of their health.
• Exceptions to confidentiality include imminent danger to the
patient or others and certain infectious diseases.
Maysa' Sofan and Nida' Maraka 10
Examples of patient rights
11. Continuity of Care
• Continuity of Care refers to a patient’s ability to choose future
relationships with healthcare providers.
• A patient has the right to have a role in accepting or refusing
referrals to certain specialists and home treatment plans.
• This is in the patient's best interest (beneficence) because it
empowers the patient to make decisions over his or her own
treatment (autonomy).
• Continuity of care necessitates that a patient receives an
explanation of how to maintain health beyond the hospital or
clinical setting. If transfer to another facility or provider is
required, then the patient is entitled to an explanation of why this
is necessary.
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Examples of patient rights
12. Ability to Speak Against Unfair Treatment
• The ability for a patient or patient representative to elevate a
concern to a higher level when it is not being addressed by
healthcare providers in the immediate care setting.
• helps protect a patient from persons who have been subjected to
treatment that places provider desires above patient well-being.
Restraint or seclusion
• Patients have the right to be free from restraints or seclusion of
coercion.
• can only be used for immediate physical safety of patients, staff
or others and must be removed at the earliest possible time.
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Examples of patient rights
13. • To ensure adequate access of all people to expert palliative care
and good pain management.
• To avoid artificial prolongation of dying.
• To ensure adequate funds and training facilities for continuing
education and psychological support of health care professional
work in palliative care.
• To provide support and care for relatives and friends.
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Rights of the Terminally Ill
14. Patients’ Rights
In summary
• Having rights does not mean that one is bound to exercise them
• Having rights doesn’t mean that their exercise is unlimited (e.g. right to
privacy)
• Negative rights (e.g. to refuse treatment) are in general stronger than
positive ones( right to treatment).
Assuring that the rights of patients are protected requires more than
educating policy makers and health providers; it requires educating
citizens.
15. Truth Telling (Veracity)
• Information given to the patient must be truthful so that informed
decision can be made by the patient. This protects the patient’s
autonomy .
• Veracity (telling the truth) binds one to honesty.
• Truth is to be honest and creating an open ,respectful communication
with others.
The purpose of truth telling
1. To enable patients to make informed choices about health care.
2. To inform them about their situation.
3. To fosters trust in the medical profession .
4. To prevents harm, as patients who are uninformed about their
situation may fail to get medical help when they should.
5. Because of the respect due to patients as persons. Patients have a right
to be told important information that the health team have about them.
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16. Truth telling can be difficult in practice in
these conditions
1. When medical uncertainty of patient’s case.
2. When the concern that bad news might harm the patient,
or in depressed patients may lead to suicide.
3. When medical error occurs.
4. When the patient's family is opposed to truth telling.
Truth Telling (Veracity)
17. In the practice of medicine, truth telling involves:
• The provision of information not simply to enable patients to
make informed choices about health care and other aspects of
their lives but also to inform them about their situation.
• Truth telling requires accuracy and honesty.
• Telling patients their diagnosis early in the course of illness,
some people find comfort in the knowledge that physicians can
name their problem.
• Not telling patients the truth about their condition may entail
deceiving them.
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Truth Telling (Veracity)
19. Surviving Student Life Ethically
• There are special ethical challenges during a student’s years that
involve both the peculiarities of the student-supervisor or student-
professor relationship and the limits of her/his own knowledge and
experience.
• No matter the student’s age, the student years are the time when the
approach to ethical decision making in one’s professional role takes
shape.
• A student, has the advantage of coming into a situation with a fresh
perspective and can raise issues that more seasoned professionals
could miss or might gloss over.
• Professional judgment is developing in one’s student experiences.
20. Academic Misconduct
• Breaches of academic integrity can begin with plans for how to
cheat to improve one’s grade.
• For example, using someone else’s material, or lift someone’s
information without giving it the appropriate credit (i.e.,
plagiarism).
• Intent is a part of misconduct because it means that a person
has set his or her sites on wrongdoing, but for an act to be
judged as complete, academic misconduct requires conduct
that follows through on the intent.
• Academic Misconduct = Intent To Engage In Wrongdoing +
Action
21. Recognizing Academic Misconduct
An example
• Guido, Shivani, Karl, Aliana, and Jasmine are friends who always study
together. On Thursday, they have an important midterm examination
that includes about 10 pages of written material analyzing several
clinical cases. They are very nervous about this examination because it
brings together a large amount of material and they have been feeling
overloaded with all of their coursework.
Which of the following constitutes academic misconduct?
22. Recognizing Academic Misconduct
1. The five of them study together and all agree to use the same sources and
approach the problems in the same way. Yes____ No____
2. The five of them agree to text message each other during the examination if one
signals to another that help is needed and the faculty member happens to leave
the room. A set of codes will help them know which question the friend needs
help with. Yes____ No____
3. They plan to sit in the examination room in such a way that they can see each
other’s answers if necessary. Yes____ No____
4. Aliana gives the secret signal that she needs help with examination question 4b.
Guido uses text messaging to alert Aliana of her problem when the faculty
member leaves the room. Yes____ No____
5. Karl goes to a website on his handheld device and copies a description from a
similar on a case analysis but does not attribute this source. Yes____ No____
6. Jasmine is glad for plan # 3 because she is stuck on one of the questions and is
able to get back on track by something she sees on Guido’s paper. Yes____ No____
7. Karl has made some notes on the back of the label of his water bottle and uses it to
help make sure he is covering the key points. Yes____ No____
• If you know that a classmate or professional colleague is engaged in
wrongdoing, you are ethically and legally responsible for reporting it.
23. The Six-Step Process as a Student
A student has a moral responsibility to:
1. Gather relevant information from the patient or family, the patient’s clinical record, and
the supervisor, expressing serious doubts about own qualifications to supervisor if the
student has been given the authority by that person to act independently and she/ he
feels ill equipped to do so.
2. Openly share what she/ he knows about the patient and other aspects of the situation
with the health care team in an attempt to identify clinical symptoms and ethical
problems.
3. Use the knowledge and skills she/ he has, including ethical theory and approaches, to
participate in arriving at a caring response. Refrain from acts that would be wrong for
anyone to commit.
4. Be ready to help identify the best alternatives possible for patients and others who are
faced with ethical problems.
5. Remain faithful to her/his own convictions and exercise the will and courage to act on
them.
6. Give her/himself the opportunity to reflect on their action with their supervisor and
others.
24. Surviving Student Life Ethically
• As a student, you may be faced with moral distress and not
making an adequate caring response because of structural and
knowledge barriers to your acting on what is right,
compounded by anxiety and other emotions.
• As a student, your role as a moral agent includes that you are
not protected from ethical dilemmas and that you must
participate in deciding how to arrive at a caring response in a
specific situation.
• During your formative years as a student, you have an
opportunity to improve your ethics skills, although at times
they make you uncomfortable.
25. Surviving Student Life Ethically
• You have a moral duty to participate with others in seeking
practical alternatives for patients faced with difficult ethical
decisions. You have a right to receive support and guidance for
this from your faculty in both the classroom and clinic.
• Act Within the Limits of Competence and Self-Confidence.
• Act According to Convictions.
• Address Others’ Wrongdoing Constructively.
• a student’s moral support applies at every step of ethical
decision making.
26. Strategies for Success as a Moral Agent
• The most difficult situations are those that involve the report of
wrongdoing, one’s own or that of others.
• Freely use channels within your institution set up for students in your
professional program.
• It is also most helpful to reflect before reporting apparent problems.
• honor the confidentiality of everyone involved, reporting only
information that is relevant to the situation and containing the report
to documented evidence.
• If you report on an error in judgment you made, you may be asked to
justify how it happened and work with your supervisor or others to
rectify it.
27. Summary
• From the time a student enters a professional program, she/he
is a student-professional and is bound to certain duties and
guiding professional values.
• It is the mutual task of students, classroom faculty, and clinical
supervisors working together to ensure that students trust their
developing competencies and abilities, understand their role as
moral agents, and act appropriately to help ensure that a caring
response consistent with the demands of professional
responsibility are exercised.
29. Prototypes of Ethical Problems
• Prototypes are a society’s attempt to name a basic category of
something.
• Prototypes can be objects, concepts, ideas, and situations.
• Prototypes of ethical problems are recognizable as a group by
three features they have in common.
• Basic features in all the prototypes of ethical problems
• A: A moral agent (or agents)
• C: A course of action
• O: An outcome
30. Basic features in all the prototypes of ethical problems
A moral agent (or agents): A
• A person who has the moral or legal capacity to make decisions and be held responsible
for them (e.g., a signee on a contract).
• A moral agent intends the morally right course of action.
• An ethical problem requires attention to both reasoning and emotion in the process of
decision making.
The Course of Action: C
• The course of action includes the agent’s analysis, the judgment process of discriminating
the best likely resolution to the problem, and the decision to act in accordance with that
judgment.
The Outcome: O
• The outcome is the result of having taken a particular course of action.
• Some ethical approaches place much more weight on the outcome; others place moral priority on
the course of action. This is sometimes referred to as the tension between the “means” one employs
and the “ends” achieved.
31. Three Prototypes of Ethical Problems
Moral Distress
• Moral distress focuses on the agent (A) herself or himself when a situation blocks her or him from
doing what is right.
• Moral distress reflects that the moral agent experiences appropriate emotional or cognitive
discomfort, or both, because of a barrier from being the kind of professional one knows he/she
should be or from doing what one concludes is right.
• Moral distress occurs when the moral agent knows what the morally appropriate course of action is
but meets up against external barriers, internal resistance, or a high level of uncertainty.
32. Moral Distress
• Two types of barriers that create moral distress
• Type A: You Cannot Do What You Know Is Right
e.g. Practitioner knows what to do vs institutional constraints to course of action that achieves the outcome.
• Type B: You Know Something Is Wrong But Are Not Sure What
Practitioner knows that something is wrong
Not sure what it is
Course of action unclear
The barrier may not be policies practices or internal anxieties and fear but instead may be that the situation is
new or extremely complex.
Three Prototypes of Ethical Problems
33. • Moral distress often occurs because of internal barriers such as
the fear of consequence of one kind or another—real or
imagined—that appears in the professional’s awareness,
blocking action.
• Wanting to do the right thing and not having the inner strength
to do it while under the weight of anxieties and fears.
• This process, faced time after time, can result in moral residue,
an accumulation of compromises that threaten one’s integrity.7
Three Prototypes of Ethical Problems
34. Ethical Dilemma: Two Courses Diverging
• An ethical dilemma is a common type of situation that involves two (or more) morally correct
courses of action that cannot both be followed.
• to take course C1 prohibits taking course C2.
• As a result, the agent, or the responsible one is doing something right and also wrong (by not doing the other thing that is
also right).
e.g. Beneficence toward patient vs Fidelity to employer
• An ethical dilemma occurs when a moral agent is faced with two or more conflicting courses of
action but only one can be chosen as the agent attempts to bring about an outcome consistent with
the professional goal of a caring response.
• Ethical dilemmas involve both ethical conflict and conduct.
• A special case of a dilemma involves justice issues when there is not enough supply of a needed
resource or service.
Three Prototypes of Ethical Problems
35. Locus of Authority Problem
• A locus of authority ethical problem arises from an ethical question of who should have the authority
to make an important ethical decision.
• who is the rightful moral agent (A) to carry out the course of action (C) and be held responsible for
the outcome (O)?
• Locus of authority problems most often arise when ambiguities exist about who is in charge.
• Locus of authority situations focus on problems determining the appropriate moral agent in a
situation. Conflicts often can be resolved with an analysis of who has the most expertise, the
traditional practices regarding who makes what decisions, an appeal to policies, and respect for
experience. The goal is to achieve an outcome consistent with a caring response.
Three Prototypes of Ethical Problems
36. A clinical Case
• Loretta is a physical therapist specializing in diabetic foot care. She sees Louise monthly. Louise is
quite down when she hobbles into the clinic today, her ankles bandaged, with blood oozing through
the gauze. She tells Loretta, “I’m sure my feet are much worse this month. I haven’t been so good
about my sugar, and it didn’t help that my husband hit my ankles with his cane twice last week. I
think he is upset about my taxi fare to get here. I think I’ll stop coming.” She begins to cry.
• What are the clinical, legal, and ethical questions that face Loretta in this case?
• What should she do?
