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Scott Rae
                        Moral
                       Choices


Thursday 17 May 2012
MAKING ETHICAL
                         DECISIONS




                           Chapter 4
Thursday 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 weighting
Thursday 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 values
Thursday 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
   doctors
Thursday 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 treatment
Thursday 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 son
Thursday 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 case
Thursday 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 truth
Thursday 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 respected



Thursday 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
   respected
Thursday 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

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Rae, Moral Choices: Ch4 - Making ethical decisions

  • 1. Scott Rae Moral Choices Thursday 17 May 2012
  • 2. MAKING ETHICAL DECISIONS Chapter 4 Thursday 17 May 2012
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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 Thursday 17 May 2012
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. - 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 Thursday 17 May 2012
  • 15. - 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
  • 16. 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
  • 17. 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
  • 18. - 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
  • 19. - 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 Thursday 17 May 2012
  • 20. 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 Thursday 17 May 2012
  • 21. - 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 Thursday 17 May 2012
  • 22. 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
  • 23. - 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 Thursday 17 May 2012
  • 24. 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 Thursday 17 May 2012
  • 25. 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 Thursday 17 May 2012
  • 26. 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 Thursday 17 May 2012
  • 27. 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