Method to Arrive at an Ethical Decision
On 5-24-2001 I put the following summary up on my now inactive "Bioethics Discussion Pages". As with other postings which I have migrated from the "Pages" to this blog, I add this one. ..Maurice.
The Method to Arrive at an Ethical Decision
This presentation is based in part on a handout by Susan Rubin, Ph.D. and Laurie Zoloth, Ph.D. for a session at the 3rd Annual Meeting of the American Society for Bioethics and Humanities October 26,2000 titled "The Theory and Practice of Clinical Ethics: Charting a Course for Effective Consultation"
In a message dated 4/15/01 7:25:36 AM, raymond@bernett.per.sg wrote me the following: "What do you think are the questions that should come to mind when confronted with a ethical or moral question?"
Since I am involved in hospital ethics committee consultations what he requests is something which also must be of concern to me performing this activity. The questions he asks about are steps in a method for decision-making for ethical issues. Obviously, the method need not only be applied to clinical hospital ethical dilemmas and conflicts but can be used for many other bioethical issues. I wrote him back the following answer to his request:
1) What is the question? Define clearly the question or issue-We should make sure we understand exactly what is asked or what is the conflict.
2) What are the facts related to the question?- This is the most important element and often incompletely obtained.
3) What ethical or moral principles are involved? Consider:
Beneficence-the commitment to do good and promote well being
Nonmaleficience-the commitment to avoid or minimize harm
Autonomy-the commitment to respect the capacity and right of individuals to choose their own values and goals and to decide for themselves what happens to their body and their lives
Justice-the commitment to fairness, to giving each individual his due and to equitably allocate collective resources
Veracity-the commitment to truth telling
Fidelity-the commitment to promise keeping
Community- the commitment of taking into account the needs, interests, contribution and role of the community and acknowledging the way in which individuals are embedded to varous degrees in complicated relationships and broader connections which might not be readily apparent
4) What are the options? What are the answers or actions to take in order to resolve the question?
5) In order to resolve the ethical or moral question and selecting an option of action we must decide which principle, on balance, will result in the more good compared with competing principles. But in making this decision one must also consider the following concerns:
Consequences-the likely impact of each option on all parties involved
Rights-establishing whether basic rights are at stake and considering the correlative obligations
Duties-essential obligations we have for one another
Respect for Persons-value certain actions which lead to human flourishing and to value people who have the potential for such actions
Virtues-which include integrity, compassion, honesty and fidelity
Cost-Effectiveness and Justice-consideration of fairness to be taken into account in weighing the distribution and balance of the benefits and burdens of each option
6) Finally, the decision of the better option can be assisted by utilizing casuistry-Is this ethical question similar to one which a consensus has previously been obtained and therefore should we use that decision in the present question? Or the narrative approach-use of foundational stories to understand the nature of the ethical dilemma and the role and perspective of each stakeholder.
It is important to remember that the answer or option worked out by this method may not be final or absolute but may have to be revisited as time goes on and the facts change.
posted by Maurice Bernstein, M.D. @ 12:45:00 PM
2 comments
2 Comments:
Here are a few questions and comments I have about these guidelines. I know there are far more than can be coherently responded to in a single coherent document. I would be interested in responses to even one of them.
3) What ethical or moral principles are involved?
How do we rank the duties (the "principles" listed seem to describe duties)? Or, less simplistically, how do we decide which duties trump others in various situations where they may seem to conflict. Is there a reliable, describable method that will apply across many cases? If not, are we to wing it? How can you advise someone who would choose a different action than you because although he agreed on the relevant, and potentially conflicting duties, he prioritized them differently than you?
How do we decide what counts as a duty? What's so special about these duties? What if I claim to be bound by quite different duties than you (and have justification with which you may or may not agree, or count as such)?
4) What are the options?
Are actions legal because they are moral, or moral because they are legal? Are our ethics external to our mere laws (let's keep in mind that we have poorly written laws, bad laws, and laws whose true meaning is to be determined by case law)? When deciding on the most ethical course of action (or potentially ethical choices of action), should we restrict ourselves to merely the set of actions that happens to be currently legal? This seems to me to be a principle of limited imagination. We are inventing new technologies and opening cans of worms faster than law can cope. Are we to sit around and wait for it? Lobbyists for many interests work to change the law over time in ways favorable to their employers. How will we know what to lobby for in time if we are habitually squeamish about entertaining illegal options as possible courses of (in our case ethical) action?
Consequences
How do we weigh the relative values of potential possible worlds in which different anticipated outcomes have obtained? How do we realistically assess the probability/possibility of potentially possible outcomes? How do we resolve potential disagreements in these assessments? How can we account for unintended/unanticipated/long-term consequences? Can desired intended consequences sometimes outweigh potentially unpalatable means? Do we judge by the actual consequences of the action (which the agent cannot know at the time the decision is made), or by the intended consequences of the agent? There are more problems with the concept of intention than you might imagine. http://www.pitt.edu/~machery/papers/The%20folk%20concept%20of%20intentionality_machery.pdf
Rights
We often speak as if we have them (it is expedient). (I like living in a society where we all act as if we have rights {most of the time}) But what are "rights" really? Where do they come from? Can/should they (ever) be taken away? How? By whom? Which rights do we have? Which rights should we have?
Respect for Persons-value certain actions which lead to human flourishing and to value people who have the potential for such actions
What gives a being moral value? How much moral value do ants, mice, dogs (they probably have the same potential for physical pain), chimpanzees (they might even have persistent desires and interests), unborn babies (earlier potential humans?), unborn babies with congenital disorders that cause mental retardation (their potential function might be less than that of a healthy chimpanzee), regular babies (potential humans?), adult humans have? Is it okay to torture any of them for fun? (A halfway decent test of whether they have *any* moral value) (Maybe moral value is the source of rights, but then where does it come from, or why do some things have it, and some have more or less?)
MK, of course you are asking valid questions within the entire commentary. I would like my visitors to join in and express their answers to your concerns.
I can give you my experienced opinion for 3) where you ask "How do we rank the duties (the 'principles' listed seem to describe duties)? Or, less simplistically, how do we decide which duties trump others in various situations where they may seem to conflict. Is there a reliable, describable method that will apply across many cases?" An answer to the first question, and which can apply to most of the questions you ask in your commentary, would be "since each case is unique, from the facts." To the second question, I would give the same answer, though society by consensus has stressed the significance of some over others, such as the rejection, at present, of "bedside rationing" such that the act of beneficence for an individual patient may trump that of justice with regard to the allocation of scarce resources.
There is no simple, mechanical or mathematical method for decision-making in ethics, particularly clinical ethics where sick individuals are the subject of these decisions. The history and the clinical facts of the case and in the light of the legal and ethics consensus leads to a decision. But ethical decisions, despite knowing the facts, must also be based in the context of the various stakeholders beyond that solely of the patient and so even though one could argue strongly toward one decision, sometimes it is necessary to end up with a mediated compromise.
That is why, our hospital ethics consultation committee session with the stakeholders may take over an hour of communication to facilitate a decision accepted by all. ..Maurice.
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