ETHICAL DECISION MAKING

Geraldine S. Canete, MAN, RN

Health care delivery system has undergone notable changes during the last few decades that includes
Increased client participation, shorter hospital stays and restructuring services (outpatient clinics, short-
stay units, long-term care and in home-care).

The dynamic changes contributed to the development of new clinical environment and expanded practice.
At present, nurses frequently encounter difficult situations involving decisions about the best course of
action. Furthermore, nurses are obligated to provide not only expanding nursing care but also ethical and
legal client care that demonstrates respect for others. Consequently, nurses confront not only the
expanding role and ever-changing clinical environment but also various ethical or moral problems and
concerns.

What are these moral or ethical problems that nurses are facing?
Jameton (1984) described 3 different types of moral problems:

Moral uncertainty
The nurse identifies a moral problem but is unsure of the morally correct action.

Moral distress:
Moral distress is the physical or emotional anguish that is experienced when we are prevented from
following the course of action that we believe is right. We may be prevented from doing what we think is
right by facility policy or procedure, influence from the patient and/or family, direction from a supervisor,
or limited time. When the nurses are unable to follow their moral beliefs because of institutional or other
restriction. The distress occurs when the nurse violates a personal moral value and fails to fulfill perceived
responsibility.
Moral distress also happen when two or more mutually exclusive moral claims clearly apply and both seem
to have equal weight. Moral distress represent practical, rather than ethical dilemmas.

Moral outrage
The nurse knows the morally correct action and feels a responsibility to the patient, but institutional or
other restraints make it nearly impossible to follow through with appropriate action. Occurs when someone
else in the health care setting performs an act the nurse believes to be immoral. Nurses do not participate
in the act. Nurses not responsible for wrong but perceive that they are powerless to prevent.

Examples of Ethical Concerns in Nursing

Patient Freedom Versus Nurse Control
• Nurses are highly educated and therefore aware of the best clinical course of action when one
exists. But what happens when a patient rejects medical advice and makes a decision that may
result in less optimal outcomes?
• From deciding whether or not a labor and delivery patient would benefit from pain medication,
to encouraging a patient to eat when they are refusing food, nurses walk a fine line everyday.

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 • While nurses do not sign the Hippocratic Oath, they are still bound by the promise to devote
themselves to the welfare of the patients committed to the care, as well as to live up to the
standards of the profession.

Suicide
The argument rages even today about whether or not people have the right to die when they choose to
die.
Do patients who are terminal and suffering have the right to die through assisted suicide?
Nursing is about promoting quality care and saving lives through resources and our own caring capacity
for other people. How should nurses approach the topic of assisted suicide?

Lying to Patients
It is not uncommon for a family member to demand that their loved one not be told they have a terminal
illness. It is equally tempting for healthcare professionals to shine the reality by telling a patient that they
are worse off than they truly are.

The Battle of Beliefs: Empirical Knowledge and Personal Belief

What is science-based, empirical knowledge to a nurse might be completely subjective to a patient with
a particular set of religious or personal beliefs. Certain religions forbid medical procedures which can mean
the difference between life and death. For example, in some cultures and religions, blood transfusions –
even lifesaving ones – are unacceptable.

Utilization of Resources
Resources are defined as tools used to provide patient care. Those tools include bed space, government
reimbursements, funding, etc.
How should nurses approach ethical dilemma when patients are utilizing resources that might be better
used on another patient or population of patients. The example for this dilemma would be a patient that
has no brain function, is on life support and has been for several years.

Other dilemmas
1) Inappropriate Medication Orders
2) Unresponsive Physicians
3) Inappropriate Tasks

Scenario of Ethical Dilemma in Nursing

Patient has stevens-johnson syndrome with uncertain prognosis (50/50 chance). pt arrests, is unconscious
vented and needs dopamine to maintain her bp constantly. pt revealed to family and nurse prior to arrest
that she doesnt wish to be kept alive should she become a "vegetable". she also has an advanced care
directive stating that should she become terminal, she doesn't wish for life sustaining measures. nurse says
to doctor that perhaps we should discontinue treatment in accordance with pt and family wishes. doctor
says no. but nurse hangs a bag of normal saline, labels it dopamine, pt arrests and dies. was this ethical?

Despite the nurses ability to deal with patients’ physical problems, many nurses feel inadequate when
confronted with ethical dilemmas associated with patient care. These feelings may stem from their
unfamiliarity with a systematic problem-solving technique for ethical dilemmas.

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How do the nurse handle those moral or ethical concerns/problems?

Nurses are able to deal with the mentioned concerns if she has moral courage and has a well-developed
ethical decision making skills.

ON MORAL COURAGE
Moral courage can be defined as taking action to do what is right in spite of possible repercussions. The
phrase “moral courage” suggests there is danger or fear associated with taking a right action, because of
the possible personal sacrifice.

Moral courage is the individual’s capacity to overcome fear and stand up for his or her core values. It puts
principles into action. Also, moral courage enables individuals to admit to wrongdoing and ethical
dilemmas steadfastly and self-confidently.

MORAL COURAGE CODE:

1. C = courage to be moral requires
2. O = obligations to honor (what is the right thing to do?)
3. D = danger to manage (what do I need to handle my fear?)
4. E = expression and action (what action do I need to take to maintain my integrity?)

Moral courage is a means to triumph over fear through practical action. Knowing professional obligations
and personal values is not the same as communicating and acting on those obligations and values……the
space between knowing and acting is bridged by moral courage…

Moral courage is easily practiced if the individual has personal integrity and moral imagination, a
heightened sense of moral integrity.
Personal integrity
• Integrity is defined as an adherence to moral principles or values
• Moral imagination
• Concerned with whether one has “a sense of the variety of possibilities and moral
consequences of their decisions, the ability to imagine a wide range of possible issues,
consequences, and solutions” (Werhane, 1998:76)

ON MORAL INTEGRITY
This heightened sense of moral integrity is facilitated through moral discernment and conscience
formation. Conscience, etymologically means “with knowledge”. This knowledge enables the individual
to have a heightened moral imagination being able to recognize a variety of possibilities and moral
consequences based on existing broad base of knowledge.

Principle of Moral Discernment

To make a conscientious ethical decision one must do the following:
1. Proceed on the basis of a fundamental commitment to God and to human persons (including
oneself) according to their God-given and graced human nature
2. Among possible actions that might seem to be means of fulfilling that commitment, exclude any
that are contradictory to it (or those that are intrinsically evil)

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 3. Consider how one’s own motives and other circumstances may contribute to or nullify the
effectiveness of these other possible actions as means to fulfill one’s fundamental commitment.
4. Among the possible means not excluded or nullified, select one by which one is most likely to
fulfill that commitment and act on it.

ON CONSCIENCE
Conscience is the practical judgment of reason upon individual act as either good and to be performed
or as evil and to be avoided. It follows personal freedom and autonomy. It is the capacity to make
practical judgments in matters involving ethical issues. It involves reasoning about moral principles Must
be rooted in reality and truth and not on mere will or desire or blind choice.

A sound, true and certain conscience develop from own perception, sound education, understanding of
natural law, traditional wisdom, teachings of family and Church, experience. Conscience though can be
in error as when one misunderstands principles, misjudges facts or is led by misguided affections. One is
culpable of an erroneous decision of conscience only within one’s capability and freedom to prevent the
error.

CONSCIENCE FORMATION
• Diligently learning the laws of moral life
• Seeking expert advice on difficult cases
• Asking God for light through prayer
• Removing the obstacles to right judgment
• Personal examination of conscience “ My conscience is my guide”
“ What I don’t know can’t hurt me” “ It is God’s will”

Principle of Well-Formed Conscience

-To attain the true goals of human life by responsible actions, in every free decision involving an ethical
question, people are morally obliged to do the following:

A. Informed themselves as fully as practically possible about the facts and the ethical norms
B. Form a morally certain judgment of conscience on the basis of this information
C. Act according to this well-formed conscience
D. Accept responsibility for their actions

Key points on Conscience Formation

1. Making moral decisions demand mature responsibility
2. A fully mature and responsible conscience should be free, correct, clear and certain
3. Discern what is right and what is wrong
4. We must follow our decision only after we have done our best to search for the truth regarding
the issues facing us

Qualities of Conscience
1. Personal Freedom- should be free from some obstacles such as fear and anger.
2. Objective value –

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 correct – subjective conforms to the objective moral values
objective – norms of morality
erroneous – lack of conformity to the objective normas of morality
culpable – one is in error and therefore responsible
Inculpable – has erred in good faith
3. Moral Attitude –
Lax – careless in its effort to seek the truth
Strict – follow to the letter
Scrupulous – tends to judge sin to be present when there is none.
Pharisaical – judgmental towards others
Clear –
Callous – worst type – no sensitivity to sin.
4. Degree of certitude –
Perplexed – wrong if you don’t do; wrong if you did.
Doubtful – lack of sufficient evidence
Probable – made a decision already but still admitting the possibility that the opposite is true.
Certain – sure. With sufficient factual evidence.

ON DECISION- MAKING
The process follows a similar pattern in most circumstances, includes: gathering data, comparing options,
using some criteria for weighing the merit of each option, and making a choice. Also, evaluation of
outcomes provides more data regarding the rightness of the choice.

Ethical decision making particularly is imperative to arrive at an ethical action or intervention.

Ethical decision-making would require an ethical judgment and such judgment we previously discussed
that it needs a basis. A specific reference point, a criteria or. condition so we can examine, evaluate then
judge and consequently act ethically.

As nurse, when do we employ ethical decision making?

Nurses employ ETHICAL DECISION MAKING whenever there are Ethical Dilemma.

An ethical dilemma or ethical paradox is a decision-making problem between two possible moral
imperatives, neither of which is unambiguously acceptable or preferable.

The complexity arises out of the situational conflict in which obeying one would result in transgressing
another. Sometimes called ethical paradoxes in moral philosophy, ethical dilemmas may be invoked to
refute an ethical system or moral code, or to improve it so as to resolve the paradox.

ON ETHICAL DECISION MAKING

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Decisions about right and wrong permeate everyday life. Ethics should concern all levels of life: acting
properly as individuals, creating responsible organizations and governments, and making our society as a
whole more ethical.

An ethical decision is one that engenders trust, and thus indicates responsibility, fairness and caring.
Ethical decision-making requires a review of different options, eliminating those with an unethical
standpoint, and then choosing the best ethical alternative.

Ethical decisions come from a place of conscience. For many, conscience is simply an internal source
of reward and punishment. But according to researcher Lawrence Kohlberg, conscience is only one of
several ways in which ethical values are represented in the personality. Kohlberg believes there are higher
levels of moral development and these are acquired in three stages.

Ethical Decision-making Process is the processes of choosing the best alternative for achieving the best
results or outcomes compliance with individual and social values, moral, and regulations.

Making good ethical decisions to solve Ethical Dilemma requires a trained sensitivity to ethical issues and
a practiced method for exploring the ethical aspects of a decision.

Having a method for ethical decision making is absolutely essential.

Ethical decision should be based on ethical principles and codes rather than on emotions, thoughts, fixed
policies.

The ethical decision-making process provides a method for nurses to answer key questions about ethical
dilemmas and to organize their thinking in a more logical and sequential manner.

The process of making ethical decisions requires:

• Commitment: The desire to do the right thing regardless of the cost
• Consciousness: The awareness to act consistently and apply moral convictions to daily behavior
• Competency: The ability to collect and evaluate information, develop alternatives, and foresee
potential consequences and risks

Good decisions are both ethical and effective:

• Ethical decisions generate and sustain trust; demonstrate respect, responsibility, fairness and
caring; and are consistent with good citizenship. These behaviors provide a foundation for making
better decisions by setting the ground rules for our behavior.
• Effective decisions are effective if they accomplish what we want accomplished and if they advance
our purposes. A choice that produces unintended and undesirable results is ineffective. The key
to making effective decisions is to think about choices in terms of their ability to accomplish our
most important goals. This means we have to understand the difference between immediate and
short-term goals and longer-range goals.

Consequences of unethical behaviors:

• Criminal charges and/or fines

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 • Lawsuits
• Ruined careers
• Injured organization reputation
• Wasted time
• Low morale
• Recruiting difficulties
• Oppressive legislation
• Fraud and scandal
To develop ethical decision making, one must understand the different influences on ethical decision
making. Oxford University identified individual and situational influences which eventually helps a nurse
become more self-aware as to the influences that shape his or her moral stand, ethical judgment, and
ethical decisions.
Individual Influence on Ethical decision making
Factor Influence on ethical decision-making

Age and gender Very mixed evidence leading to unclear associations with ethical decision-
making.

National and cultural Appear to have a significant effect on ethical beliefs, as well as views of what
characteristics is deemed an acceptable approach to certain business issues.

• People from different cultural backgrounds likely to have different

beliefs about right and wrong, different values, etc. and this will
inevitably lead to variations in ethical decision-making across
nations, religions and cultures
• Hofstede (1980; 1994) influential in shaping our understanding of
these differences – our ‘mental programming’
– Individualism/collectivism
– Power distance
– Uncertainty avoidance
– Masculinity/femininity

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 Somewhat unclear, although some clear differences in ethical decision-
Education and making between those with different educational and professional
employment experience seem to be present.

Psychological factors:
Cognitive moral Small but significant effect on ethical decision-making.
development
At most a limited effect on decision-making, but can be important in
Locus of control predicting the apportioning of blame/approbation.

• Cognitive moral development (CMD) refers to the different levels of

reasoning that an individual can apply to ethical issues and
problems
– Criticisms of CMD
• Gender bias
• Implicit value judgements
• Invariance of stages
• An individual’s locus of control determines the extent to which they
believe that they have control over the events in their life

Personal integrity Significant influence likely, but lack of inclusion in models and empirical tests

Moral imagination A new issue for inclusion with considerable explanatory potential

© Oxford University Press, 2005. All rights reserved.

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Situational influences on decision-making
Type of factor Factor Influence on ethical decision-making

Moral intensity Reasonably new factor, but evidence suggests

Issue-related significant effect on ethical decision-making.

Moral framing Fairly limited evidence, but existing studies show

strong influence on some aspects of the ethical
decision-making process, most notably moral
awareness.

Strong evidence of relationship between

Rewards rewards/punishments and ethical behaviour, although
other stages in ethical decision-making have been less
investigated.

Authority Good general support for a significant influence from

immediate superiors and top management on ethical
Context-related decision-making of subordinates

Bureaucracy Significant influence on ethical decision-making well

documented, but actually exposed to only limited
empirical research. Hence, specific consequences for
ethical decision-making remain contested.

Work roles Some influence likely, but lack of empirical evidence to

date

Organizational culture Strong overall influence, although implications of

relationship between culture and ethical decision-
making remain contested.

National context Limited empirical investigation, but some shifts in

influence likely.
© Oxford University Press, 2005. All rights reserved.

Moral Intensity
• Jones (1991:374-8) proposes that the intensity of an issue will vary according to six factors:
– Magnitude of consequences
– Social consensus
– Probability of effect
– Temporal immediacy
– Proximity
– Concentration of effect

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Moral framing
• The same problem or dilemma can be perceived very differently according to the way that the
issue is framed
– Language important aspect of moral framing
• Moral muteness (Bird & Walters 1989) because of:
– Harmony
– Efficiency
– Image of power and effectiveness
Systems of reward:
• Adherence to ethical principles and standards stands less chance of being repeated and spread
throughout a company when it goes unnoticed and unrewarded
– “What is right in the corporation is not what is right in a man’s home or in his church. What
is right in the corporation is what the guy above you wants from you. That’s what morality
is in the corporation” (Jackall, 1988:6)
Authority
• People do what they are told to do – or what they think they’re being told to do

Bureaucracy
• Bauman (1989, 1993) and ten Bos (1997) argue bureaucracy has a number of effects on ethical
decision-making
• Suppression of moral autonomy
• Instrumental morality
• Distancing
• Denial of moral status
Work roles
• Work roles can encapsulate a whole set of expectations about what to value, how to relate to
others, and how to behave

Organisational norms and culture

• the group norms which delineate acceptable standards of behaviour within the work community

National and cultural context

• This differs from individual’s national and cultural characteristics
• Instead of looking at the nationality of the individual making the decision; now we are considering
the nation in which the decision is actually taking place, regardless of the decision-maker’s
nationality
• Different cultures still to some extent maintain different views of what is right and wrong

FRAMEWORK FOR ETHICAL DECISION-MAKING:

Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced
method for exploring the ethical aspects of a decision and weighing the considerations that should impact
our choice of a course of action. Having a method for ethical decision making is essential. When practiced
regularly, the method becomes so familiar that we work through it automatically without consulting the

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specific steps. This is one reason why we can sometimes say that we have a “moral intuition” about a
certain situation, even when we have not consciously thought through the issue. We are able to practice
making ethical judgments, just as we can practice at playing the piano, and can sit and play well “without
thinking.” Nevertheless, it is not always advisable to follow our immediate intuitions, especially in
particularly complicated or unfamiliar situations.

The method presented here, unlike some others, is based on the nursing process. It should be
relatively easy for the nurse to move from the nursing process used in resolving patient physical problems
to the ethical decision-making process used in resolving ethical problems.

Nursing Process and the Ethical Decision-Making Model

NURSING PROCESS ETHICAL DECISION-MAKING PROCESS

Assess Assess the situation and gather all information relevant to the case ;

Ask what are the relevant facts of the case?

Clarify issues and Gather Data on the elements of the issue (Act itself, The
intent, The Circumstances), the keyplayers in the issues
Diagnosis Diagnose the moral problem _ morally acceptable or morally unacceptable,
Morally licit or morally illicit.

Analyze the elements of the issue (Act, intention, Circumstances) if good or

bad and if there are violation and non-violations of ethical principles code of
ethics then come up with a, ethical judgment if acceptable or not.

Ask what is the nature of the problem in this case?

Plan Make a decision based on the ethical judgment Set moral goals and plan of
course of action aimed at achieving a morally just outcome;

Ask – How best can the client’s best interests(wellbeing &welfare) be

maximized in this case?

Implement Act on it, participate on initiatives and advocacy if needed

This could involve range of actions –reporting the matter to the supervisor

/manager/involvement of an institutional ethics committee for advice

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 Evaluate Evaluate the outcome of the plan of action implemented.

Ask –Has the desired moral outcome been achieved in this case.

CONCLUSIONS
Nurses encounter various ethical issues in the practice of her profession hence must be skilled not only in
clinical decision making but also in ethical decision making to be able to manage well in the face of both
clinical and ethical or moral problems, be it moral uncertainty, moral distress or moral outrage.

A person who is in doubt and lacks knowledge cannot decide and one who is indecisive about which is
the better good, cannot act. Hence a well-formed conscience and moral courage are important to be able
to make ethical decisions. A deep sense of moral integrity to act according to the ethical principles and
dictates of the professional code of ethics are necessary in successfully implementing or doing such ethical
actions and decisions for the benefit of the patient and the health care environment in its entirety.
Openness for corrections and commitment to lifelong learning will motivate the nurse to continue to
evaluate the impact of her ethical decisions thus strengthening his or her will for moral fortitude.

In the final analysis, Ethical decision making makes the practice of nursing safe, effective and reliable.

REFERENCES:

Edge, R. & Groves, J. (2019) Ethics of Health Care: A Guide for Clinical Practice. 4th ed. Philippine Edition:
Cengage Learning Asia Pte. Ltd.,.

Monge, M. (2014) Ethics in Medical Practice: Summary, Explanation & Defense of Concrete Ethical
Problems. Revised Edition. Manila: Sinagtala Publishers

Ocampo, M. L. R. (2018) Ethics Primer A Young Person’s Guide to Moral Reasoning. Vibal Group, Inc.

Rice, C. (1996) 50 Questions on the Natural Law: What It Is & Why We Need It. Ignatius Press,

Scgreccia, E. (2012) Personalist Bioethics: Foundations and Applications (T. Di Camillo, J. & Miller, M.
Translation). The National Catholic Bioethics Center. 2007, 1998, 1994, 198

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