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Ethical Decision Making


Bioethics: the application of ethics to health care. Ethical Principles. Nonmaleficence ... Problem or issue: a situation in which important moral values are ... – PowerPoint PPT presentation

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Title: Ethical Decision Making

Ethical Decision Making
Morality and Moral Values
  • Personal morality
  • Societal morality
  • Group morality

Decisions and Actions Rules and Codes Moral
Principles Ethical Theories Moral Philosophy
Moral Philosophy
  • Teleological the end justifies the means
  • Deontological the means need to be carefully
    weighed without primary concern for the outcome

Ethical Theories
  • Descriptive Ethics Moral system of a group or
  • Normative Ethics Moral system used to make moral
  • Bioethics the application of ethics to health

Ethical Principles
  • Nonmaleficence
  • Beneficence
  • Autonomy
  • Justice
  • Distributive
  • Compensatory (and retributive)
  • Procedural

Rules and Codes
  • Fidelity being faithful to ones clients,
    employer and colleagues
  • Confidentiality (privacy) keeping non-relevant
    information private
  • Veracity telling the truth not lying
  • APTA Code of Ethics
  • FIU Student Code of Standards

The Nature of Ethical Principles
  • Fundamentalism the philosophical stance that
    ethical principles are universal
  • Multiculturalism the anthropological stance that
    ethical principles are culturally-bound

Crigger NJ, Holcomb L, Weiss J. Fundamentalism,
multiculturalism and problems of conducting
research with populations in developing nations.
Nursing Ethics. 20018(5)459-468.
Possible Cultural Differences
  • Individualism Communitarianism
  • Autonomy . Family decision-making
  • Individual liberty .... Social/common good
  • The individual .... The collective
  • Individual rights .. Personal virtues
  • Individual development .... Family and filial
  • Contract .... Trust
  • Self-determination ..... Self-examination
  • Freedom .Duty and obligation

Nie J-B. The plurality of Chinese and American
medical moralities Toward an interpretive
cross-cultural bioethics. Kennedy Institute of
Ethics Journal. 200010(3)239-260.
Contrasting Norms, Cultural Beliefs and Values
  • Self-reliance and individualism lead to valuing
    individual autonomy
  • Informed consent advanced directives
  • Porous social groups
  • The individual as part of the larger whole values
    group cohesion
  • Group decides if patient is told what to do
  • Social groups resist outsiders

Davis AJ. Global influence of American nursing
some ethical issues. Nursing Ethics.
The Realm-Individual Process-Situation (RIPS)
Model of Ethical Decision Making
  • A formalized approach to reflection and analysis
    of morality

Four Step Process
  • Step I Recognize and define the ethical issue
    (realm, individual process and situation)
  • Step II Reflect
  • Step III Decide the right thing to do
  • Step IV Implement, evaluate and reassess

Components of the RIPS Model
Realm Individual Process Ethical Situation
Individual Institutional/ Organizational Societal Moral Sensitivity Moral Judgment Moral Motivation Moral Courage Problem or issue Temptation Distress Dilemma Silence
  • Individual realm concerned with the good of the
    patient/client and focuses on rights, duties,
    relationships and behaviors between individuals
  • Institutional/organizational realm concerned
    with the good of the organization and focuses on
    structures and systems that will facilitate their
  • Societal realm concerned with the common good

Individual Process
  • Moral sensitivity recognizing, interpreting and
    framing ethical situations
  • Moral judgment deciding between right and wrong
    actions considering ethical principles
    (autonomy, etc), then selecting and applying them
  • Moral motivation prioritizing ethical values
    over financial gain or self-interest
  • Moral courage implementing the chosen ethical
    action, even though doing so may cause adversity

Ethical Situation
  • Problem or issue a situation in which important
    moral values are being challenged
  • Temptation a situation in which a choice must be
    made between a right action and a wrong action,
    where the wrong action may benefit the
    decision-maker in some way
  • Silence key parties realize ethical values are
    being challenged, but do nothing
  • Distress
  • Dilemma

Ethical Distress
  • Ethical distress there is a structural barrier
    to doing the right thing
  • Type A There is a barrier keeping you from doing
    what you know is right
  • Type B There is a barrier because something is
    wrong, but you are not sure what that something

Ethical Dilemma
  • There are two (or more) correct courses of action
    that cannot both be followed.
  • You are doing something right, and also something
  • Most often involve ethical conduct (e.g. honoring
    autonomy vs. preventing harm).
  • May involve conflicting traits of character (e.g.
    honesty vs. compassion)

Step II Reflect
  • What are the relevant facts and contextual
  • Who are the major stakeholders?
  • What are the potential consequences, intended or
  • What are the relevant laws, duties, and ethical
  • What professional guidance do we have?
  • What do the right vs. wrong tests suggest you
    should do?

Right vs. Wrong
  • The legal test Did anyone do anything illegal?
  • The stench test Does the situation smell
  • Publicity (the front page test) Would any of
    the parties involved be embarrassed by the truth
    coming out?
  • Universality (the mom test) What would your
    mom do? Is this the right thing to do regardless
    of whos involved?
  • The ethics test Do the Code of Ethics, the Guide
    to Professional Conduct, or Professionalism in
    Physical Therapy Core Values, say anything about
    this situation?

Cultural Issues
  • Explicitly acknowledge patients cultural norms,
    beliefs and values
  • Locate the patients individual beliefs
  • Be explicit about the process of decision-making
    that generally guides your actions
  • Come to an agreement between all parties (perhaps
    including the family) on what information will be
    given and to whom.

Irvine R, McPhee J, Kerridge IH. The challenge of
cultural and ethical pluralism to medical
practice. MJA. 2002176175-176.
Step III Decide What To Do
  • Rule-based Follow only the principle you want
    every one else to follow (deontological)
  • Ends-based Do whatever produces the greatest
    good for the greatest number (teleological)
  • Care-based Do onto others as you would have them
    do onto you (the golden rule)

Step IV Implement, Evaluate and Reassess
  • Implement moral courage (role-play, prepare,
  • Evaluate and reassess
  • Did things turn out the way you expected?
  • What did you do well? Not so well?
  • What were the most challenging aspects of this
  • How did this situation compare with others you
    have encountered or read about?
  • How will this experience make you a better