Chapter 2: Ethical Decision Making
- 2.1 Describe and compare need and value development theories.
- 2.2 Identify the major principles of contemporary consequence-oriented, duty-oriented, and virtue ethics reasoning.
- 2.3 Define the basic principles of health care ethics.
Introduction
Healthcare ethical decision-making is a structured process that helps professionals navigate complex situations where moral principles, patient rights, and clinical responsibilities intersect. It ensures that care is delivered with integrity, fairness, and respect for individual dignity.
Understanding and applying ethical principles is essential for healthcare professionals to provide compassionate, fair, and effective care. Ethical decisions are often required in situations such as:
- End-of-life care decisions
- Informed consent
- Resource allocation
- Confidentiality and privacy
- Cultural and religious considerations
Need and Value Development Theories
These psychological and sociological frameworks explain how human needs and values emerge, evolve, and influence behavior. They are essential for understanding motivation, development, and social change.
Need Development Theories
- Maslow’s Hierarchy of Needs: Five levels—physiological, safety, love/belonging, esteem, and self-actualization. Lower needs must be met before higher ones motivate behavior.
- Erikson’s Psychosocial Development: Eight life stages, each with a key conflict (e.g., trust vs. mistrust). Useful for understanding personal growth across the lifespan.
- Self-Determination Theory (Deci & Ryan): Emphasizes autonomy, competence, and relatedness as essential psychological needs.
Value Development Theories
- Kohlberg’s Moral Development: Stages of moral reasoning from obedience to universal ethics. Important for understanding ethical maturity.
- Schwartz’s Basic Human Values: Identifies universal values (e.g., security, benevolence) and how they relate across cultures.
- Inglehart’s Value Change Theory: Explains shifts from survival to self-expression values in modern societies.
Importance of These Theories
- Clarify human motivation and decision-making
- Guide education, therapy, and policy interventions
- Support personal development and goal-setting
- Explain cultural and generational value shifts
Principles of Ethical Reasoning
Consequence-Oriented Reasoning (Consequentialism)
This ethical framework judges actions based on their outcomes. It includes modern utilitarianism and public health ethics.
- Outcome-Based Evaluation: Right actions maximize good outcomes.
- Maximization of Value: Often includes happiness, health, sustainability, etc.
- Impartiality: All affected individuals count equally.
- Measurability: Outcomes can be quantified and compared.
- Context Sensitivity: Real-world complexity is considered.
- Forward-Looking: Focuses on future impact and prevention.
- Adaptability: Flexible to changing information and conditions.
- Transparency: Decision-makers should explain their reasoning.
Health Care Examples:
- Allocating ICU beds during a pandemic based on the likelihood of survival
- Mandating vaccinations to achieve herd immunity
- Enforcing quarantines to protect public health
Duty-Oriented Reasoning (Deontology)
This approach evaluates whether actions follow moral duties or rules, regardless of their consequences.
- Right or Wrong in Itself: Actions are judged by principles, not outcomes.
- Universal Moral Duties: Apply to everyone equally (e.g., do not kill).
- Respect for Persons: Treat individuals as ends, not means.
- Intentions Matter: Motive is central to moral worth.
- Rule-Based: Follows ethical, legal, or religious codes.
- Moral Responsibility: Duty must be upheld even under pressure.
Health Care Example: A physician refuses to assist in euthanasia out of duty to preserve life, even if it would relieve patient suffering.
Virtue Ethics Reasoning
Virtue ethics focuses on moral character rather than rules or outcomes. It emphasizes being a good person who cultivates virtues through practice.
- Character-Centered: Good people make good decisions.
- Virtues: Traits like honesty, compassion, courage, justice, temperance.
- Habitual Practice: Virtues are developed through repetition and reflection.
- The Golden Mean: Virtue lies between excess and deficiency.
- Practical Wisdom: Knowing the right thing to do in complex situations.
- Community and Role Models: Ethics is shaped by example and culture.
- Flourishing (Eudaimonia): The goal is a meaningful, purposeful life.
Health Care Example: A nurse reports a colleague’s medication error out of integrity and commitment to patient safety—not because a rule requires it, but because it’s the right thing to do.
Basic Principles of Health Care Ethics
These four principles guide ethical decision-making in medicine:
- Autonomy: Respecting a patient’s right to make informed decisions.
- Beneficence: Acting in the patient’s best interest.
- Non-maleficence: “Do no harm”—avoiding unnecessary risk or injury.
- Justice: Treating patients fairly and equitably.
Real-World Case Examples
Case Example: A Jehovah’s Witness Refuses a Blood Transfusion
Scenario:
A 35-year-old woman who is a Jehovah’s Witness is admitted to the hospital with severe blood loss after a car accident. She is alert and clearly states that, due to her religious beliefs, she refuses any blood transfusions—even if her life is at risk.
Application of the Four Principles:
- Autonomy
The patient has the right to refuse treatment, even if it may result in death. Respecting her decision honors her autonomy. - Beneficence
The medical team wants to save her life, which they believe is in her best interest. They look for alternative treatments (e.g., volume expanders, medications) that can help without violating her beliefs. - Non-maleficence
Administering a blood transfusion against her will may cause psychological harm and violate her deeply held beliefs. Thus, forcing treatment could be more harmful than beneficial. - Justice
She is entitled to the same standard of care as any other patient, even though her treatment choices are different. The hospital must ensure resources are still used fairly and respectfully.
This example shows how the principles can sometimes be in tension—like beneficence versus autonomy—and how ethical decision-making often involves balancing these principles carefully.
Case Example: Terminal Cancer Patient Declines Further Treatment
Scenario:
A 70-year-old man with advanced pancreatic cancer is offered chemotherapy that may prolong his life by a few months but will likely cause significant side effects. After discussing the risks and benefits with his physician, he decides to decline further treatment and opts for hospice care to focus on comfort and quality of life.
Application of the Four Principles:
- Autonomy
The patient’s decision to decline chemotherapy is respected. He is fully informed and mentally competent, so he has the right to choose how he lives out his final days. - Beneficence
The care team supports his choice by providing palliative care aimed at comfort, not cure. This honors his values and prioritizes his well-being. - Non-maleficence
Forcing unwanted chemotherapy could cause harm (nausea, weakness, emotional distress) without meaningful benefit. Avoiding that harm aligns with this principle. - Justice
The patient is given equal access to hospice and support services regardless of his choice to refuse aggressive treatment.
This case underscores the importance of informed consent, where the patient receives all necessary information to make a voluntary and educated decision about their care.
Case Example: Parents Refuse Chemotherapy for a Child
Scenario:
A 10-year-old child is diagnosed with a highly treatable form of leukemia. Doctors recommend chemotherapy with a high chance of cure. However, the parents—based on religious beliefs—refuse treatment, opting instead for natural remedies. The child expresses a desire to live and appears afraid of dying.
Application of the Four Principles:
- Autonomy
Children have developing autonomy. While not legally able to make medical decisions alone, their voice is ethically important—especially when they are old enough to understand the situation. The child’s wish to live carries moral weight. - Beneficence
The medical team knows that chemotherapy offers a strong chance of curing the child. Acting in the child’s best interest means advocating for life-saving treatment. - Non-maleficence
Withholding effective treatment is likely to result in the child’s death, which constitutes preventable harm. - Justice
All children should have access to potentially curative care, regardless of parental beliefs. The child’s right to health and life must be weighed against parental rights.
Ethical Dilemma: In many places, this situation would lead to court intervention, where a judge could temporarily suspend parental rights to allow treatment, protecting the child’s welfare.
This example shows how pediatric ethics can be especially complex, as the balance between parental rights and the child’s best interests can be contentious.
Summary
Healthcare ethical decision-making ensures care aligns with professional standards and moral values. By grounding decisions in consequence-oriented, duty-based, and character-based reasoning, professionals can uphold the principles of autonomy, beneficence, non-maleficence, and justice.
Ethics promotes compassionate, equitable care and strengthens public trust in the healthcare system. Ongoing reflection, education, and collaboration are essential for navigating ethical challenges with integrity.
Media Attributions
- A group of multiethnic medical professionals including doctors, surgeons, and nurses are gathered in a hospital setting discussing patient care and using modern technology to address challenges in the medical field.