Better Practice

Making the case for ethical

decision-making models
Richard Jason Cooper
how nurse prescribers can be assisted in
Abstract making ethical decisions will be provided
Ethical decision making is an important aspect of nurse prescribing and, although by describing the benefits of ethical
the literature has provided ample guidance of the role of ethical theories, much decision-making models and also providing
less attention has been given to more practical guidance, such as ethical decision- guidance on avoiding mistakes in ethical
making models. This article argues that such models are helpful resources and arguments. Although dozens of ethical
despite their considerable diversity, they may be summarized into key aspects decision-making models exist, it will be
relating to: identifying the problem and gathering facts, considering others in terms argued that there are a number of key stages
of their values and opinions, finding options and justifying one choice, and then that nurse prescribers should consider. The
implementing it. The article also provides a further resource relating to avoiding second resource is a brief guide to making
common mistakes in reasoning when making an ethical decision in prescribing. ethical arguments—a skill that is arguably
fundamental to making and justifying
ethical decisions, but one that has been

T he need for nurse prescribers to be

able to make effective ethical decisions
requires little justification. In nursing, as
ethics. Elsewhere, Cooper (2010) and
Adams (2011) suggested that an awareness
of several theories, including deontological
neglected in the nursing literature.

in healthcare more generally, it is widely
recognized that ethical problems are both
inevitable and that health practitioners,
including nurses, are ethically accountable
for their work. In relation to prescribing,
ethical concerns include the influence
of the pharmaceutical industry, self-
prescribing, consent and capacity,
prescribing beyond competencies, pressure
from patients and peers, and issues of
distributive justice to name but a few
(Scottish Executive Health Department,
2006; Cooper, 2010). However, nurse
prescribers seeking guidance and support
in ethical aspects of prescribing may
be forgiven for being confused rather
than enlightened based on the variety
of different suggestions available in the
literature. In this journal, Amoroso
and Otway (2006) suggested the use of
Seedhouse’s model of inner and outer
layers to consider the ethical implications
of nurse prescribing, and Lovatt (2010)
espoused the use of Beauchamp and
Childress’ four principles of biomedical
Richard Jason Cooper is a Lecturer in Public
Health at the University of Sheffield
Email: richard.cooper@sheffield.ac.uk
Why models?
duty, utilitarian consequences, and the A reasonable question any nurse prescriber
four principles of biomedical ethics of might ask at this point is: why is there a
autonomy, beneficence, non-maleficence, need for ethical decision making to be
and justice were needed, to be able to formalized in terms of a model? There are a
reflect adequately on ethical issues relating range of answers to this question, and these
to nurse prescribing. are summarized in Box 1, but fundamentally
This article intentionally avoids such such models attempt to improve the
approaches and instead draws upon quality of decision making and encourage
more practical and pragmatic resources prescribers to move away from the merely
to explore and provide guidance about intuitive and give them a set of important
ethical decision making. No attempt will factors that should be considered (Cooper,
be made to revisit and explain the key 2007; Park, 2012). And as Fry and Johnston
ethical theories that have been advanced (2002, page 56–57) note ‘all of them provide
over the years, and instead guidance on an orderly approach to analyzing both the
Box 1. Reasons for using models
To simplify and clarify moral perplexity
■■
To predict what an individual will do
■■
To identify practical or logistical aspects of ethical decision making
■■
To provide a tool for documenting or auditing decision
■■
To enable good communication of a decision
■■
To shift emphasis away from decisions based on personal intuition alone
■■
To allow information to be collected to assess ethical norms
■■
To present stages that appear to have worked in practice
■■
To uncover where differences of opinion or belief exist
■■
To ensure all those affected by the proposed decision have been considered
■■
and given opportunity to contribute
To consider ethical issues alongside codes and relevant legal factors
■■

Nurse Prescribing 2012 Vol 10 No 12 607

Better Practice

‘factual’ and value dimensions involved

Implement
in ethical conflicts and offer a systematic

argument;
decision

if you can
Find best
counter-
approach to implementing ethical decision

rebut it,
decide
in patient care’.

Content of the models

consistency,
Unfortunately, despite the benefits

concepts,
based on
described above, an initial problem

and logic
Choose
concerns the sheer variety of different

option
models available in the literature. Park
(2012), for example, identified no less
than twenty models that were considered

arguments
Generate options and make ethical decision
relevant to nursing, Cooper (2007)

pros and
Identify

cons of
identified another 10 distinct models (Table

moral
1), and Fry and Johnstone (2002) described
several more too. The reason for this
variety may be attributed to the different

What does
intended audiences of each model (which

decision

the law
range from the general to the specific, from

Make

say?
disciplines as wide ranging as business,
social work, and the health professions),
and to contested claims about what each

significant
Generate

model should contain. As Table 1 illustrates

decision

parts of
options

Identify

options
morally
Table 1. Examples of ethical decision-making models

apply?
and Park (2012) identified, some models

might
Make

What
other
rules
were relatively brief while others contained
much more detail and additional stages.
However, it is possible to identify, in many,
and ascribe

a core set of steps or stages, which may be

the range
Generate

of ethical
Consider
Prioritize

possible
theories
options

options
summarized as:
values

List
■ Identifying an ethical problem, based
on gathering of all relevant facts
c) Determine who
Think of others

■ Thinking of others (whose views are

is involved and

important, who can help, who ought to

should decide
Consider who

make the decision)

their values

■ From possible options, making the

ethical decision
■ Implementing the ethical decision.

In reducing the various models to

statements;

evaluations
Define who
Distinguish

Distinguish
Gather facts: law, codes,

should act
Identify problem and

non-moral
moral and
evaluative
gather relevant facts

facts from

and when
professional knowledge

this core of four stages, the aim is not to

undermine the complexity, uniqueness,
and subtlety of the models that have
a)

b)

been developed over the decades, but

Make decision

instead to assist the nurse prescriber

situation is
an ethical

in understanding the core activities

Consider

problem
whether

relevant
are the

associated with ethical decision making.

facts?
What

A further rationale for providing this

by:

summary is that individual models are

not immune from problems. As Table
correspondence);

1 indicates, some models seem to omit

Pellegrino (1987)
Weinstein (1996)

Haddad (1999)
Badcott (2007)

or leave implicit obvious stages, such as

Wingfield and

Parker (2006,

adapted from

making a final decision and implementing

Veatch and

it, and Park (2012) observed that some

personal
Author

method

models appear to proceed to finding

solutions without identifying and stating
the exact ethical problem in hand. It is

608 Nurse Prescribing 2012 Vol 10 No 12

 Better Practice

to this first identification stage that this

Act ethically

article now moves on to.

Implement
Identifying ethical issues
This first common stage may be thought of
an obvious one, but there are good reasons
for including it as the initial stage in
ethical decision making in prescribing.
Firstly, it may be that some problems
contain no ethical element or value
conflict at all, and could be decided by an

Final decision
assessment of facts alone. A patient who
demands an expensive brand of medicine,
which it transpires has been unavailable
owing to a manufacturing problem, is
an example where it is not necessary (at
least not at that moment) to pursue an

possibilities
ethical solution, when the fundamental
with sound
arguments
decisions

Consider
practical
fact of unavailability is the deciding factor.
Justify

This stage also enables the gathering of

information that relate to law, codes of
ethics, and other guidance. Doing so at
this stage may permit the identification
legal, and
Establish

religious,
is found,

decision
analysis
solution

cultural

of an issue that could possibly be resolved

Ethical
factors
ethical
critical

about
moral

Think
intent

apply

through legal procedures (British Medical

If no

Association, 2004). A good example

here relates to breaches of confidentiality
professional

that may be permitted in a prescribing

reasoning
reasoning

guidance
legal and

quality of
Consider

consultation where a nurse prescriber

relevant
Identify

Ethical
ethical

becomes aware of information that

Apply

indicates a real and serious threat to

life

another. Existing legal and professional

guidance is clear that if an obvious
What is the
experience

situations?

threat exists to another individual, it is

in similar

Seek information from

of others

permissible for the nurse prescriber to

patient and others

breach confidentiality and inform other

Identify patient’s

relevant parties, such as the police.

preferences

However, the main reason for this

of others?
reasoned
What are

stage is to enable a proper and thorough

opinions

ethical decision to be made, and one

that is based on as comprehensive and
accurate a set of circumstances and facts
as possible. Without all of the relevant
perception
How have

into parts
Identify ethical problem

facts, it is obvious that any decision made

I acted in

Establish medical facts

dilemma

Ethical

will be inappropriate as it has not taken

Break
past?

down

account of all relevant factors. Finally,

this stage recognizes that identifying
ethical issues and associated facts is a
experience
Recognize

skill and is something to be developed,

What are

personal
situation
my core
beliefs?

tells us

and that there is a danger if it is omitted,

ethical

What

as it may lead to ethical issues being

overlooked (Cooper et al, 2008).
Schneider

Jonsen et
and Snell

Think of others
al (1992)
(1986),

Evident in many models is the need to

(2004)
(2000)

(1997)
(1991)
Jones

Holm
BMA
Rest

consider a range of possible individuals

based on different aspects of ethical

Nurse Prescribing 2012 Vol 10 No 12 609

Better Practice
decision making. Firstly, it is necessary in
terms of the need to consider those affected
by a decision (arguably a consequentialist
informed approach) to understand their
views, opinions, and insights as well
as considering issues of autonomy and
dignity. Those affected could include not
only the prescriber and the patient, but also
the patient’s family, as well as other health
professionals, and even the wider public, if
broader consequences and issues of justice
are considered. Secondly, thinking of
others is related to whether another person
may be more appropriately placed to make
an ethical decision. In many cases, this
will be the actual nurse prescriber—as the
person who identifies the problem initially
of course—but, in some instances, this may
not be appropriate. For example, if a nurse
prescriber becomes aware of inappropriate
prescribing by a colleague, they may
not feel they have sufficient evidence or
information or clinical knowledge to
make a decision about whistle-blowing,
but it may be appropriate to discuss this
with their line manager or a more senior
or experienced colleague and to allow
them to make an ethical decision. A final
concern about others relates to identifying
those who may be able to give advice on
the decision (Schneider and Snell, 2000).
This is a relatively unusual perspective but
has links to theories, such as Habermas’
discourse ethics and the need to explore
ethical problems in not only an open way
but also in a way that values the dialogue
between individuals, rather than in
isolation (Habermas, 1990; Cooper, 2009).
Make and justify decision
The third main feature of ethical decision
making models is to identify possible
actions or outcomes, which are based
on an assessment of the relevant facts,
and then to choose one of them. Implicit
in this stage is that these options, and
the final decision, must be ethically
justified. The aim in these stages is to
enable reflection on the possibility of
different options and actions, and not to
make hasty assumptions or convenient
decisions. However, within this stage is
perhaps the most complex and significant
part of the decision-making model—the
justification. This must be done based
on defensible arguments and these will
often be drawn from the broader moral
610
philosophy literature. While it is not the require prescribers to think about how a
purpose of this article to review this, it may new problem may be accommodated in
be helpful to think of this stage as being existing ethical frameworks and theories.
one that in recent years has rejected the One further resource that may assist
traditional and fixed ‘top down’ approach nurse prescribers is to consider ways in
where only one ethical theory may be used. which justification for an ethical decision
Instead, a more accommodating process can be made. One way in which this can be
of valuing the unique nature of the ethical done is to not remember what to do, but
problem, as well as personal beliefs and instead what not to do, and to recognize a
ethical theory have been influential, after number of common mistakes or fallacies in
the work of Rawls (1979) and Beauchamp argument when justifying ethical decisions.
and Childress (2001). Such an approach, Such fallacies have been recognized in the
referred to as one of reflective equilibrium, medical ethics literature, but apply equally
has been championed because no to nurse prescribing and nursing ethics, and
ethical theory has been developed that is provide a useful but neglected perspective
uncontested and not considered to have on strengthening an ethical argument
possible drawbacks. Further, such reflective through avoiding mistakes (Table 2)
approaches may be easier to accommodate (Hope et al, 2008). As the table indicates,
with personal views and beliefs, and, in the there are a range of different arguments or
rapidly expanding field of healthcare, new claims that have been invoked to defend
ethical problems are always emerging that a decision or argument, but are ethically
Table 2. Examples of ethical fallacies that
must be avoided (Hope et al, 2008)
Ad hominem Shifting claim to an irrelevant aspect of person
making the argument: ‘Claire was wrong not to
prescribe that mother antibiotics for her daughter, as
she has no children’
Authority claims Arguing a claim is correct simply because someone
in authority has said it: ‘Prescribing by brand is fine
if the drug representative has been to talk to you;
consultants at this hospital do it all the time’
Begging the question Including conclusion or disputed point as an assumed
point in reasoning: ‘If letting patients use heroin
bought on the street were not illegal, then there
wouldn’t be laws to stop it’
Dissenters Identifying those who disagree with an argument
does not in itself show the argument is not valid (see
authority claims)
Motherhoods Inserting a soft statement to disguise a contentious
one: ‘all human are equal (so we shouldn’t stop
treatment for a patient in a persistent vegetative state)’
Confusing necessary Assuming something is the only requirement for an
and sufficient outcome, when it is only one aspect; ‘a nurse prescriber
may be guilty of negligence because they have a duty
of care to a patient’ is true, but it is only one requirement
and others are needed for actual negligence
No true Scotsman! Attempts to defend an initial claim when it is
challenged by appeals to rhetoric; ‘No Scottish nurse
would kill his patient’; ‘But it’s just been reported that
one did’, ‘Well, no true Scottish nurse would!’
Nurse Prescribing 2012 Vol 10 No 12

and logically challengable and false. For
the nurse prescriber seeking to justify a
prescribing decision, these arguments or
claims must always be avoided. They serve
as a reminder, and as examples of poor
arguments, and should encourage nurse
prescribers to more robustly defend their
ethical decision.
Implement ethical decision
This stage may seem, like the first stage,
quite obvious when first considered,
since if an ethical decision is made,
then that should be enough. However,
empirical evidence and hypotheses from
moral psychology suggest that this is not
always the case, and it is possible for an
individual to know what they ought to
do but not to actually do anything (Rest,
1986; Cooper, et al, 2008). This links into
appeals in nursing that there is a need for
ethical action, as a broader professional
aim (Fry and Johnson, 2002). Such ethical
inaction has been termed ethical passivity
and may be manifest in waiting for
another person to act, or to deferring to
another’s judgement, both of which may
be inappropriate (Cooper et al, 2008).
Not apparent in any of the models
in Table 1, but identified by Park (2012)
in several more general nursing ethical
decision-making models, is an evaluation
stage. The inclusion of this stage is arguably
influenced by the importance of evaluation
in nursing generally, and Park (20120
argues that it is evaluation of the ethical
decision and not the later implementation
that is important for quality.
Limitations
Although this article is intended to
guide nurse and other prescribers in
ethical decision making through the use
of models, a few notes of caution are
needed. Firstly, such models are ‘empty’
in the sense that they provide a set of
stages and a framework, but contain no
hint as to what the ethical reasoning
process should involve. This is left entirely
to the nurse prescriber. Some models
have been arguably validated through
empirical study of nurses in practice, or
have anecdotal evidence to support them
(Parker, 2006, personal correspondence;
Park, 2012). However, such models are
best considered as helpful aide memoires
or stages, to be used alongside and not
Nurse Prescribing 2012 Vol 10 No 12
Better Practice
Key Points
■ A range of ethical decision-making models exist that complement but do not
replace existing theories and that may enhance the quality of decision making
■ Four key aspects of models include: identifying an ethical problem and
gathering relevant facts and information; considering others in terms of impact,
views, and opinions; identifying different possible options and choosing and
justifying one option; and, finally, implementing the decision
■ There are a number of common mistakes or fallacies that nurse prescribers
should avoid when justifying their ethical prescribing decision
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