Ethical Decision Making: Black, White and Shades of Gray

Ethical Decision Making:
Black, White, and Shades of Grey
Mary Eleanor Wickersham, D.P.A.
School of Business and Public Affairs
College of Coastal Georgia
Required for
sensitivity to
moral issues;
ability to see
moral conflict
for what it is and
to think
creatively about
“solutions that
are . . . morally
(Patricia Werhane)
Foundation of
good laws is
Laws are the Regulation are the
basis of
basis of
Conflicting Claims
• Autonomy vs. nonmaleficence
• Autonomy vs. beneficence
• Justice vs. necessity
• Justice vs. fairness
• Friendship vs. fairness
• Quality of life vs. safety
• Necessity vs. patient demand
• Cost vs. outcomes
• Long-term vs. short-term
• Religious beliefs vs. professional goals
• Mistakes vs. intentional wrongdoing
Sources of conflict
Warring family members
Provider disagreement
Professional uncertainty
Disagreement about outcomes
Lack of resources
Differing motivations: outcomes vs. cost;
research goals vs. patient outcomes; facility
bottom line vs. patient needs/outcomes
Guides for Decision Making
• Often helpful to have a tool to guide decision making;
we will examine several
• Sometimes, you need expertise of either a mediator or
ethics consultant or professional expertise
• Decision making takes practice
• Groupthink is the antithesis of good decision-making
• Despite what you’ve heard, brainstorming has
• Sometimes there are no good solutions, so we must
seek the “least-worst” alternative
Case Analysis: SFNO
• SFNO method works well for clinical cases, but
also other types of decision making
• Easy to remember
• Identifying norms takes practice
– Community norms, ethical norms, legal norms,
social and cultural norms
DuBois’ “So Far, No Objections”
• Stakeholders
– who will be significantly affected by the decision
(institutional/individual); who are they and what are their
positions; can be the source of the dilemma
• Facts
– What are the facts surrounding the case (sometimes
requires research); sometimes the source of the dilemma
• Norms
– What are the ethical principles at stake? Where do they
conflict? Often the source of the dilemma.
• Options
– What actions or policies deserve serious consideration? If
there is no clear answer, what compromise solutions are
most attractive?
Dubois, James. “A Framework for Analyzing Ethics
Cases.” EMHR Network.
Ethics Committee – Case One
• Ms. Jones was readmitted to your facility after a four-day
stay at the hospital. She is back in her room at the SNF and
she is having IV antibiotics for 7 days. She is doing well,
though she appears depressed. Her daughter visits from
her home in another state and demands that her mother
be sent back to the hospital where she can have a higher
level of care. Since her daughter has arrived, Ms. Jones says
that her condition has worsened and she would get better
care in an acute setting.
Who are the stakeholders in this discussion?
What are the facts of the case?
What are the norms to be considered?
What are your options?
What is the decision?
Case Analysis: Moral Reasoning Tool
• Sources of conflict:
– Family issues
– SFNO works well, but there are other helpful tools
like Moral Reasoning Tool
– One mandate is that decision-makers – in this case
your ethics committee – must agree on the ethical
dilemma. Sometimes that is easier said that done.
The Moral Reasoning Tool works well as a guide to
help you reach consensus.
The Moral Reasoning Process
• Description of Facts
• Identification of Principles and Values
• Statement of ethical issue or question
• Weighing of competing principles and values
• Consideration of external values
• Examination of duties to various parties
• Discussion of applicable ethical theories
• Rendering of moral agent’s decision (ethics committee)
• Defense of that decision based on moral theory (how do you justify
Day, L.A. (2003). Ethics in media communications:
Cases & controversies. Belmont, CA: Wadsworth.
Ethics Committee – Case Two
• Anne is having extreme difficulty in making the decision to
forego nutrition and hydration for her mother, who at 89
appears to be in the final stages of Alzheimer’s disease.
Anne’s mother lived with her and her husband for 15 years
before coming to the nursing home, and he is pressuring
her to ask for a feeding tube. Anything less, he says, would
be tantamount to murder. The doctor, who told Anne her
mother’s case was “hopeless,” has worries about the moral
implications of his recommendation not to use a feeding
• Is this a common scenario in your facility? Why do you
think this happens? What does CMS tell us about our goal
in nursing homes? Do you think this scenario is an ethical
• Use the moral reasoning device to work on this case.
Case Analysis: Ethics Tests
• Sources of conflict:
– Provider disagreements
– Marketing issues
– Lack of resources
– Conflict of interest/competing motivations
– Employee issues
• Ethics Test has questions to guide
committee/decision-maker through ethical
thought process
Dunfee, Smith, and Ross: Ethical Tests
Thomas W. Dunfee, N. Craig Smith, and William T. Ross, “Social Contracts and Marketing Ethics,” Journal of Marketing, 63 (July): 14-32, 1999
• Does the contemplated action violate the law?” (Legal Test)
• Is this action contrary to widely accepted moral obligations? (Duties Test)
• Does the proposed action violate any other special obligations? (Special
Obligations Test)
• Is the intent of the contemplated action harmful? (Motives Test)
• Is it likely that any major damages to people or organizations will result
from the contemplated action? (Consequences Test)
• Is there a satisfactory alternative action that produces equal or greater
benefits to the parties affected than the proposed action? (Utilitarian Test)
• Does the contemplated action infringe upon property rights, privacy
rights, or the inalienable rights of the consumer? (Rights Test)
• Does the proposed action leave another person or group less well off? Is
this person or group already a member of a relatively underprivileged
class? (Justice Test)
If the answer of any of these questions is yes, then the issue needs to be
studied further. (From Social Contracts and Marketing Ethics).
Ethics Committee – Case Three
• Twenty percent of the beds in your facility are empty. You
were approached last week by a new hospice organization
that says that they are interested in contracting with the
nursing home at the prevailing rate and they are willing to
comply with facility rules about management of the care
plan. One proviso, however, is that they are trying to build
census, and just from their tour of the facility, they believe
that there are patients in your facility who might quality for
hospice care. They would like to screen all of the patients
to determine eligibility. Incidentally, the marketing person
told you, they have two to three people in the community
who need a higher level of service and might be interested
in nursing home care
• Use the Dunfee, Smith, and Ross method to discuss this
Case Analysis: C.L.I.C.K.
• Sources of conflict:
– Employee issues
– PR issues (visitors, volunteers, larger community)
– Dilemmas with regulators, other outside entities
– Corporate conflict
– Good for compliance committees
• Easy to remember, can be taught, works well
for non-professionals
Pearl Moore’s CLICK method
• Consequence: What are the consequences if I do
this? Who will benefit? Who will suffer?
• Legal: Is it legal?
• Image: Would I like to see this on the front page
of the newspaper? Would I feel good telling this
to my friends and family?
• Culture: Does this decision support or damage
our organization’s culture and values?
• Know: Does doing this cause a knot in my
Pearl Moore, “Ethical Decision Making Will Yield Favorable Outcomes,” ONS News, July 2003, Vol. 18, Issue 7, p. 15.
Compliance Committee – Case Four
• You have established a Code of Ethics in your facility,
you’ve educated staff, and all of the employees have
signed off on it. The code clearly states that gifts of
more than a nominal value may not be accepted by
staff. Nominal is considered to be less than $15. A
report has just come in your hotline that one of your
longest, most dependable, and best-loved employees,
who is set to retire next year, six months ago accepted
an old car from the family of a resident who died.
• What do you do?
• Sometimes there are no good answers and
nobody is happy with outcome
• Important to have a process that can be put into
place quickly
– Ethics and compliance committee should be in place;
not necessarily the same group
• It takes practice to gain confidence, but practice
will help with other everyday decisions
• Sometimes need to consider outside facilitator
Thank you.
Mary Eleanor Wickersham, DPA
School of Business and Public Affairs
College of Coastal Georgia
1 College Drive
Brunswick, GA 31520
[email protected]

similar documents