Be alert! Be sensitive to morally charged situations. Ethical dilemmas rarely present themselves as such. Look behind the technical requirements of your job to see the moral dimensions. Important clues include conflicts between two or more values or ideals. Identify what you know and don't know. While you gather information, be open to alternative interpretations of events. Within the bounds of patient and institutional confidentiality, make sure that you have the perspectives of patients and families as well as health care providers and administrators. While accuracy and thoroughness are important, there can be a trade-off between gathering more information and letting morally significant options disappear. Decisions may have to be made before the full story is known.

• How is the problem an ethical issue?

What is the problem? What are its opposing points? Who defines it as a problem? How did it get defined? Is there something wrong personally, interpersonally, or socially? Is there conflict that could be damaging to people? (or animals?) To the environment, institutions, society? Does the issue go deeper than legal or institutional concerns? What does it do to people as persons who have dignity, rights and hopes for a better life together? What decisions have to be made?

• What are the facts?

What immediate facts have the most bearing on the ethical decision you need to make? Also include in this list any potential health, economic, social, or political pressures.

• Who are the stakeholders?

Who is affected by the decision? Often there are more parties whose interests should be taken into consideration than is immediately obvious. Be imaginative and sympathetic. Remember that there may be more than one decision-maker and that their interactions can be important. Look at the relationships between the parties. Look at their relationships with yourself and with each other, and with relevant institutions. What do you think each of these stakeholders would prefer that you do regarding this issue?

• What (and whose) values are involved?

Think through the shared values that are at stake in making this decision. Is there a question of trust? Is personal autonomy a consideration? Is there a question of fairness? Is anyone to be harmed or helped? How do the values and principles of stakeholders conflict? What are the personal motives and intentions of the various parties? Whose needs and interests are being served? By whom? How do values get prioritized? Be alert to actual or potential conflict of interest situations. A conflict of interest is a "situation in which a person, such as a public official, an employee, or a professional, has a private or personal interest sufficient to appear to a reasonable person to influence the objective exercise of his or her official duties." These include financial conflicts of interest (e.g., favoritism to a friend or relative). In some situations, it is sufficient to make known to all parties that you are in a conflict of interest situation. In other cases, it is essential to step out of a decision-making role.

 

How is power distributed or shared among the players in this situation? Is there any abuse of power? What other questions about power do you have?

 

Note here a caveat about one's own convictions, belief system, judgments, etc. which may or may not enter into the mix. Sometimes, let's say re. abortion, one may have strong personal beliefs but they have to be put aside when one is part of someone else's decision-making process. That's one of the stickiest areas: feeling "I'm a person of principle and want to act out of my convictions," and yet being a part of someone else's process of deciding and acting. In situations like these, the care professional has to always be taking her/his own temp: "Where is my 'absolutely not...under no circumstances' threshold?"

• What is the benefit/burden ratio?

Benefits--broadly defined--might include such things as the production of goods (physical, emotional, financial, social, etc.) for various parties, the satisfaction of preferences, and acting in accord with various relevant values (such as fairness).

Burdens might include causing physical or emotional pain to various parties, imposing financial costs, and ignoring relevant values.

• Are there alternatives?

Identify clinical issues, patient's preferences, quality of life/death issues, and contextual features. What are the decision-making options for each of these, and what are the likely consequences of various decisions? Take into account good or bad consequences not just for yourself, your profession, organization or patients, but for all affected persons. Be honest about your own stake in particular outcomes.

 

What option will produce the most good and do the least harm? Which option respects the rights and dignity of all stakeholders? Which option promotes the common good? Which option enables the development of the virtues or character traits that we value as individuals, as a profession, as a society? Select the best alternative, all things considered; consider your choice critically.

• Are there analogous cases?

Can you think of other similar decisions? What course of action was taken? Was it a good decision? How is the present case like that one? How is it different?

• What do your ethical resources say?

Ethical principles: autonomy (Are we exploiting?), non-maleficence (Will this harm anyone?), beneficence (Will this do good or prevent harm?), justice (Are we treating everyone fairly?), fidelity (Are we being faithful to professional roles?).

 

Use ethically informed sources, e.g., policies, professional norms, legal precedents, ethics committees and consultants, and wisdom from religious and cultural traditions.

• Who should be involved in the decision-making?

The merits of discussion should not be underestimated. Time permitting, discuss your decision with as many persons as have a stake in it. Gather opinions, and ask for the reasons behind those opinions. Remember that your ability to discuss with others may be limited by the other person's expectations of confidentiality.

• What is the context of the decision-making?

Ask yourself why this decision is being made in this context at this time? Are there better contexts for making this decision? Are the right decision-makers included?

• Is the decision legal and in accord with organizational rules?

Some decisions are appropriately made based on legal considerations. If an option is illegal, we should at least think very seriously before taking that option.

Decisions may also be affected by rules set by organizations of which we are members. For example, most professional organizations have Codes of Ethics which are intended to guide individual decision-making. Institutions such as hospitals and clinics may also have policies which limit the options available to us. Sometimes there are bad laws, or bad rules, and sometimes those would be broken. But usually it is ethically important to pay attention to laws and rules.

• Are you comfortable with the decision?

Accept responsibility for your choice. Sometimes your gut reaction will tell you if you've missed something. Ask yourself: If I carry out this decision, would I be comfortable telling my family about it? My clergyman? My mentors? Would I want children to take my behavior as an example? What would a "virtuous person"--one with integrity and experience--do in these circumstances? I Can I live with this decision? Accept the possibility that you might be wrong or that you will make a less than optimal decision. The object is to make a good choice with the information available, not to make a perfect choice. Learn from your failures and successes. If you had to do it over again, is there something you would do differently? ("Defend your decision in the form of a letter addressed to your most adamant detractor.")

 

This is not an exhaustive list of questions. But they should give you some examples of the kinds of questions to ask. Not all of them may apply to your situation. Use these as needed but in addition, formulate your own questions to get the information you need to make a decision.

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