Ethical Decision Model for Medical Dilemmas

Scott Rae
Moral
Choices

Thursday 17 May 2012

MAKING ETHICAL
DECISIONS

Chapter 4

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”.

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.

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:

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.

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.

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.

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.


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 weighting

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.


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!


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.

- 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 values

- 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)

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.

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.


- 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)


- 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
doctors

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 treatment

- 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 son

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)

- 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 case

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 truth

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 respected


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
respected

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.”

Ethical Decision Model for Medical Dilemmas

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