MODELS FOR EXAMINING ETHICAL DILEMMAS

The decision-maker must always be objective when making ethical decisions. It is critical to examine all the facts of a given situation by gathering as much information or data as possible. Alternative solutions to the problem must be assessed if they are available. All sides of every issue should be studied before ethical decisions are made. The following are three decision-making models that can be helpful when resolving ethical issues: the three-step (Blanchard-Peale) ethics model, the seven-step decision model, and Dr. Bernard Lo’s clinical model.

Three-Step Ethics Model

Kenneth Blanchard and Norman Vincent Peale advise the use of a three-step model when evaluating an ethical dilemma. The three steps are to ask yourself each of the following questions:

· Is it legal?

· Is it balanced?

· How does it make me feel?

· 1. Is it legal? When applying the three-step model, if the situation is clearly illegal, such as inflicting bodily harm on another, then the matter is also clearly unethical, and you do not even have to progress to the second question. However, if the action is not against the law, then you should ask yourself the second question.

· 2. Is it balanced? This question helps to determine if another person or group of people is negatively affected by the action. In other words, is there now an imbalance so that one person or group suffers or benefits more than another as a result of your action? For example, in the case of a scarce resource such as donor organs, does one group of people have greater access?

· 3. How does it make me feel? This final question refers to how the action will affect you emotionally. Would you be hesitant to explain your actions to a loved one? How would you feel if you saw your name in the paper associated with the action? Can you face yourself in the mirror?

If you can answer the first two questions with a strong “Yes” and the final question with a strong “Good,” then the action is likely to be ethical.

For example, student cheating is clearly unethical. By using the three-step ethics model, we have an even clearer idea of why it is unethical to look at even one answer on another student’s test. We ask the three questions:

· 1. Is it legal? Yes, as far as we know there is no law against cheating.

· 2. Is it balanced? No, it is not. This question is where the model really helps us. One group or person (in this case the cheater) does have an advantage over another group or person. In addition, the grades will be skewed for the entire class, because the person who cheated will receive a higher grade than what he or she earned.

· 3. How does it make me feel? Remember that we have to live with ourselves. The philosopher Thomas Aquinas said, “We become what we do,” meaning that if we lie, we become a liar. Or in this case, if we cheat, we become a cheater.

MED TIP

The three-step ethics model is a quick way to check yourself when you are uncomfortable about an ethical decision. Use it often!

Analysis is the ability to carefully take apart issues, restate them in your own words, and offer an interpretation, and even criticism, of them. The following two models require careful analysis of the problem.

The Seven-Step Decision Model

· I. Determine the facts by asking the following questions: What do we need to know? Who is involved in the situation? Where does the ethical situation take place? When does it occur?

· II. Define the precise ethical issue. For example, is it a matter of fairness, justice, morality, or individual rights?

· III. Identify the major principles, rules, and values. For example, is this a matter of integrity, quality, respect for others, or profit?

· IV. Specify the alternatives. List the major alternative courses of action, including those that represent some form of compromise. This may be a choice between simply doing or not doing something.

· V. Compare values and alternatives. Determine if there is one principle or value, or a combination of principles and values, that is so compelling that the proper alternative is clear.

· VI. Assess the consequences. Identify short-term, long-term, positive, and negative consequences for the major alternatives. The short-term gain or loss is often overridden when long-term consequences are considered. This step often reveals an unanticipated result of major importance.

· VII. Make a decision. The consequences are balanced against one’s primary principles or values. Always double-check your decision.

The seven-step decision model forces us to closely examine the facts before we make an ethical decision. This model is helpful when making a decision that has many subdecision questions to examine; for example, “Who should the physician treat first?” “Should I look at the exam paper of the person sitting next to me?” or even “What career choice should I make?” Obviously, some of these decisions require a quick response, while others, such as selection of a career choice, require more time and research. This model can be used to examine all of the end-of-chapter cases in this textbook.

Dr. Bernard Lo’s Clinical Model

Dr. Lo has developed a clinical model for decision-making to ensure that no important considerations relating to patient care are overlooked. He believes this approach can be used to help resolve important patient-care issues, such as when to proceed with life-sustaining interventions (e.g., cardiopulmonary resuscitation [CPR] or kidney dialysis). His model also includes the patient’s preferences and viewpoints.

· I. Gather information.

· a. If the patient is competent, what are his or her preferences for care?

· b. If the patient lacks decision-making capacity, has he or she provided advance directives for care?

· c. If the patient lacks decision-making capacity, who should act as surrogate?

· d. What are the views of the healthcare team?

· e. What other issues complicate the case?

· II. Clarify the ethical issues.

· a. What are the pertinent ethical issues?

· b. Determine the ethical guidelines that people are using.

· c. What are the reasons for and against the alternative plans of care?

· III. Resolve the dilemma.

· a. Meet with the healthcare team and with the patient or surrogate.

· b. List the alternatives of care.

· c. Negotiate a mutually acceptable decision.

Dr. Lo emphasizes that patients should play an active role in decisions. Everything should be done to ensure that the patient has been well informed by providing information in an easy-to-understand way. This model cautions the healthcare team to seek the patient’s decision on advance directives. He requires that the entire healthcare team—including medical students, nurses, social workers, and all others who provide direct care for the patient—be involved in the decisions. These caregivers should voice any moral objections they have to the proposed care. Finally, the patient’s best interests must always be protected. This model is more commonly used in a hospital or clinic setting.

MED TIP

When following a moral line of reasoning, it is always advisable to examine all of the facts rather than to predetermine what should be done.