2 Chapter 2:Ethical Decision Making

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. There are many situations we may be called upon to make ethical decisions such as:

Common Ethical Dilemmas in Healthcare

• End-of-life care decisions
  Determining when to initiate or withdraw life-sustaining treatments.​
• Informed consent
  Ensuring patients understand the risks and benefits of procedures.​
• Resource allocation
  Deciding how to distribute limited medical resources fairly.​
• Confidentiality and privacy
  Balancing the need to share patient information with the obligation to protect privacy.​

Cultural and religious considerations

Respecting diverse beliefs that may influence healthcare decisions.

Need and Value development theories

Need and value development theories are psychological and sociological frameworks that explain how and why human needs and values emerge, evolve, and influence behavior over time. These theories are essential for understanding motivation, personal growth, and societal change. Here’s a breakdown of both:

1. Need Development Theories

These theories focus on how human needs arise and develop across time, often in a hierarchical or developmental sequence. They aim to explain what drives human behavior and decision-making.

Key Theories:

• Maslow’s Hierarchy of Needs (Abraham Maslow):
  • Proposes five levels of needs: physiological, safety, love/belonging, esteem, and self-actualization.
  • Suggests that lower-level needs must be satisfied before higher-level needs become motivating.
  • Value: Helps explain motivation in both individuals and groups (e.g., workplace, education, therapy).
• Erikson’s Psychosocial Development Theory:
  • Emphasizes the development of psychosocial needs through eight life stages (e.g., trust vs. mistrust, identity vs. role confusion).
  • Value: Useful in education, counseling, and understanding life challenges at different ages.
• Self-Determination Theory (Deci & Ryan):
  • Highlights the importance of autonomy, competence, and relatedness as fundamental psychological needs.
  • Value: Influential in education, work motivation, and mental health fields.

2. Value Development Theories

These theories examine how values, principles, or standards of behavior are formed and evolve within individuals and societies.

Key Theories:

• Kohlberg’s Stages of Moral Development:
  • Describes how moral reasoning evolves in stages from basic obedience to universal ethical principles.
  • Value: Helps educators and psychologists understand moral and ethical growth in children and adults.
• Schwartz’s Theory of Basic Human Values:
  • Identifies universal values (e.g., security, power, achievement, benevolence) and their interrelationships.
  • Value: Widely used in cross-cultural psychology and global organizational research.
• Inglehart’s Theory of Value Change:
  • Argues that as societies become more economically secure, people shift from “survival values” to “self-expression values.”
  • Value: Explains cultural and political changes, such as rising environmental awareness or democratic participation.

Importance of These Theories:

• Understanding Motivation: They clarify why people behave the way they do across life stages and contexts.
• Designing Interventions: Useful in education, therapy, policymaking, and business.
• Promoting Personal Growth: Help individuals reflect on their needs, values, and life goals.
• Navigating Social Change: Provide insight into societal development and generational value shifts.

Principles of Reasoning

Consequence-Oriented Reasoning

Contemporary consequence-oriented reasoning, also known as consequentialism, focuses on evaluating the outcomes or consequences of actions to determine their moral rightness or wrongness. In modern contexts, this reasoning has evolved and diversified. Here are the key principles that define contemporary consequence-oriented reasoning:

1. Outcome-Based Evaluation

Actions are judged solely or primarily by their consequences.

A morally right action is one that maximizes good outcomes (e.g., happiness, welfare, utility).

2. Maximization of Value

Often rooted in utilitarianism, which advocates maximizing overall happiness or well-being.

Contemporary versions may consider a broader range of values: health, freedom, knowledge, and environmental sustainability.

3. Impartiality

The interests of all affected parties are considered equally.

No individual’s happiness or suffering is valued more than another’s (unless justified by context, such as need).

4. Measurability and Comparability

Encourages quantification of outcomes (e.g., cost-benefit analysis, quality-adjusted life years in healthcare).

Values must be weighed and compared, even when in conflict.

5. Context Sensitivity

Modern consequentialism takes context into account—different situations may justify different actions.

It recognizes real-world complexity (e.g., unintended consequences, systemic effects).

6. Forward-Looking

Focuses on the future impacts of actions, policies, or decisions.

Encourages preventive thinking (e.g., climate policy, AI ethics).

7. Flexibility and Adaptability

Not bound to rigid rules—ethical decisions are evaluated dynamically based on changing conditions and new information.

Emphasizes pragmatism in complex moral dilemmas.

8. Accountability and Transparency

Decision-makers should be accountable for their reasoning and outcomes.

Modern consequentialism promotes open reasoning processes, particularly in public policy and bioethics.

Application in Health Care Ethics

In health care, consequentialist reasoning is often applied to decisions that aim to achieve the best outcomes for patients and populations. For example:​

• Resource Allocation: During a pandemic, limited medical resources (like ventilators) may be allocated to patients with the highest likelihood of survival to maximize overall lives saved.​
• Vaccination Programs: Implementing widespread vaccination to achieve herd immunity considers the greater good, even if some individuals may have objections.​
• Public Health Policies: Enforcing quarantine measures to prevent disease spread focuses on the positive consequences for the broader community.

Duty-Oriented Reasoning

Duty-oriented reasoning, also known as deontological ethics, is an ethical approach where actions are judged based on whether they adhere to a set of moral duties, rules, or obligations—regardless of the consequences.

Here’s a breakdown of the core principles of duty-oriented reasoning:

1. Actions Are Right or Wrong in Themselves

Moral correctness depends on whether an action follows a rule or duty, not on its outcomes.

Example: Telling the truth is right, even if it leads to negative consequences.

2. Moral Duties Are Universal and Binding

People have obligations that apply to everyone equally, regardless of personal interests or societal norms.

“Do not kill,” “keep promises,” and “treat others with respect” are typical examples.

3. Respect for Persons (Human Dignity)

Every person must be treated as an end in themselves, never merely as a means to an end (Immanuel Kant’s principle).

This underlies ideas like informed consent, human rights, and fair treatment.

4. Intentions Matter

The motive behind an action is central to its moral worth.

A well-intended action is considered morally right, even if it leads to a bad outcome.

5. Rule-Based Ethics

Moral reasoning is grounded in clear principles or rules (e.g., religious commandments, legal codes, ethical duties).

These rules are often non-negotiable and not subject to calculation or comparison.

6. Moral Responsibility

Individuals are morally responsible for following their duties, even under pressure.

This can involve moral courage, such as whistleblowing or standing up against injustic

Examples in Practice:

A doctor refuses to perform euthanasia even if the patient is suffering, because it violates their professional duty to preserve life.

A journalist publishes a truth that may damage reputations because they believe in the duty to inform the public.

Strengths:

Provides clear moral guidance and protects rights.

Upholds integrity and consistency in ethical decisions.

Limitations:

May lead to rigid or conflicting duties (e.g., telling the truth vs. protecting someone’s safety).

May ignore consequences that could lead to greater harm.

Duty-Oriented Reasoning Approach:

• If the physician believes it is a moral duty not to kill, then even if assisted dying might end suffering, it would be inherently wrong.
• They follow the duty to preserve life, even if the outcome may not be ideal for the patient.

Virtue Ethics Reasoning

Virtue ethics reasoning is an ethical framework that focuses on the character and virtues of the moral agent, rather than on rules (duty ethics) or outcomes (consequence ethics). It asks, “What kind of person should I be?” instead of “What should I do?”

Core Principles of Virtue Ethics Reasoning

1. Focus on Moral Character

• Ethical behavior arises from the character of the individual, not just actions or consequences.
• A good person, shaped by good habits, will naturally make good choices.

2. Emphasis on Virtues

• Virtues are positive traits or qualities, like:
  • Honesty
  • Courage
  • Compassion
  • Generosity
  • Justice
  • Temperance
• Ethical living means developing and practicing these virtues consistently.

3. Moral Development Through Habit

• Virtue is not innate; it’s developed through practice, reflection, and education.
• Just as physical strength grows through exercise, moral strength grows through repeated virtuous actions.

4. The “Golden Mean” (Aristotle)

Virtue lies between deficiency and excess of a trait.

Example: Courage is the mean between cowardice (too little) and recklessness (too much).

5. Practical Wisdom (Phronesis)

A virtuous person must have practical judgment—knowing the right action in the right situation.

This helps balance competing values (e.g., truth vs. kindness).

6. Community and Role Models

Character is shaped by social relationships, culture, and role models.

Learning from exemplary individuals (e.g., parents, leaders, heroes) is crucial to moral growth.

7. Flourishing (Eudaimonia)

The ultimate goal is not just to do right, but to live well—a life of meaning, purpose, and human flourishing.

Applications in Real Life:

In healthcare: A nurse shows compassion not just because it’s a rule, but because they are a compassionate person.

In leadership: A leader is admired not for calculating benefits, but for integrity and fairness.

In education: Teaching students to become ethical citizens, not just rule-followers.

Strengths:

Promotes personal growth and deep ethical integrity.

Encourages holistic moral education and lifelong development.

Limitations:

Vagueness: What counts as a virtue can vary across cultures.

Lacks action-guidance: Doesn’t always give clear answers in moral dilemmas.

Basic Principles of Health Care Ethics

The basic principles of health care ethics, often referred to as the four principles of biomedical ethics, are:

1. Autonomy
   • Respecting a patient’s right to make their own decisions about their health and medical treatment.
   • Involves informed consent and truth-telling.
2. Beneficence
   • Promoting the well-being of patients.
   • Requires health care providers to act in the best interest of the patient by providing benefits and balancing them against risks.
3. Non-maleficence
   • “Do no harm.”
   • Avoiding actions that could cause unnecessary harm or suffering to patients.
4. Justice
   • Fair and equitable treatment of all patients.
   • Involves the fair distribution of health resources and respect for laws and rights.
   • These principles guide ethical decision-making in clinical settings and form the foundation of many medical codes of ethics.

Real Life Applications

Here’s a real-life inspired example that illustrates how the four principles of health care ethics apply:

Application of the Four Principles:

1. Autonomy
   • The patient has the right to refuse treatment, even if it may result in death. Respecting her decision honors her autonomy.
2. 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.
3. 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.
4. 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.

Here’s another example, this time involving end-of-life care and the principle of informed consent:

Application of the Four Principles:

1. 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.
2. 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.
3. Non-maleficence
   • Forcing unwanted chemotherapy could cause harm (nausea, weakness, emotional distress) without meaningful benefit. Avoiding that harm aligns with this principle.
4. 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.

Here’s a pediatric case example that highlights an ethical dilemma, especially where autonomy is limited and beneficence, non-maleficence, and justice must be carefully balanced:

Application of the Four Principles:

1. 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.
2. 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.
3. Non-maleficence
   • Withholding effective treatment is likely to result in the child’s death, which constitutes preventable harm.
4. 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.