Ethical Decision Making in

Ethical Decision Making

in the Business of Health Care
Cynthia Clark RN, MS, ACADC
March 21, 2002
Business and Management
• Business Ethics Defined and Discussed
• Health Care Management Ethics
• Theories of Moral Reasoning
• Nursing Ethics
• Ethical Principles
• Application of EDM Models

Ethics…from the Greek word ETHOS

Ethics Defined meaning custom or character
…a branch of philosophy focusing on
questions of right and wrong, concerned * Rules that govern “right” conduct
with moral good.
Encompasses: * What “ought” to be / the right thing to do
1. Ethical Theory
2. Morality * The “should” of human behavior
3. Judgement

To Help Us Make Decisions Types of Ethics

1. Vision and Mission Statements • Bioethics or Clinical Ethics
2. JCAHO Standards
3. Policies and Procedures
4. ANA Code of Ethics • Nursing Ethics
5. International Code of Ethics for Nurses
6. ANA Standards of Professional
Performance • Management or Business Ethics
 Kohlberg’s Theory of Gilligan’s Theory of Moral
Moral Development Development
…6 stages groups into 3 levels. Each Level 1 Selfishness,
level represents a fundamental shift in
1927-1987
Caring for Oneself
social-moral perspective of the
individual.
1. Punishment and Obedience Level 2 Goodness, Caring for Others
I. Preconventional 2. Naïve Hedonism

3. Good Boy/Nice Girl

II. Conventional 4. Law and Order Level 3 Non-violence, Caring for Self
5. Social Contract and Others
III. Postconventional 6. Principles of Conscience

Nursing Ethics Findings

Study about EDM processes by 24 nurses toward their patients
• Moral distress equation
Moral situation + a moral decision + the perceived
inability to act = painful feelings and psychological distress
• Gilligan’s framework was used to determine “how” nurses
dealt with the ethical dilemma
• Each told a personal, truestory and discussed “how”
they processed the dilemma and “why” they did
what they did.
Millette, 1994 Western Journal of Nursing Research
• The caring principle was evident in all cases
• In three cases the caring principle was “pure”
• In 17 cases the caring principle prevailed
• In NO case was the justice principle “pure”
• Of the 17 nurses where caring prevailed, 9 are
no longer in nursing, and none of the caring “purists”
are active in nursing
• Of the 8 still active, 4 were administrators

Questions? Most Common Theme...

• Does the justice principle assist nurses to remain in nursing?
• Does the caring principle make it harder to stay active?
• Is the justice principle more prevalent among nursing
administrators than in staff nurses?
Feeling Powerless….
• Perceived themselves as less powerful than
the employer, physician’s, supervisors,
and other team members
• Those who had greater financial security
felt freer to act on their client’s behalf
• Most nurses did not express confidence or
trust in their supervisors
 Discussion
• Nurses do not feel free to act as moral
advocates in many health care settings
• Nurses often feel powerless when they find
themselves in conflict with others over pt. care
• Many feel that their only option is to leave
• A nurse’s ability to act is directly related to
his/her perceived sense of autonomy and power
Conclusions
• Caring and justice are both evident in nursing
• Neither seems more effective in helping nurses
make moral choices
• Both guide nurses in the provision of quality
care and patient advocacy
• Nurses with a justice orientation may be more
likely to stay in nursing
• Nurses in a supportive setting who are able
collaborate effectively with other disciplines
and with each other perceive themselves as powerful

Responsibilities Expected of a Professional Nurse Five Most Frequent Ethical

Issues and Concerns in Nursing
Quality Issues Clinical and Business Combined (Chvatal, 1991)

Patient Needs Legal Issues 1. Inadequate staffing patterns

Staff Needs 2. Prolonged life with heroic measures
Organizational Needs Ethical Issues 3. Inappropriate resource allocation
4. Patient cases being discussed inappropriately
Cost Issues 5. Dealing with colleagues irresponsible activity

“ Nursing is a clinical art with moral overtones “ Chvatal, 1991

Cherry & Jacob, 1999

The most important ethical dilemma ETHICAL PRINCIPLES

facing nursing today…
• Autonomy • Nonmaleficence
… how can nurse managers and administrators
maintain their commitments to: • Justice • Veracity
(Distributive)
• universal access to care Historically the domain
of nursing commitment • Utility
• quality patient care • Fidelity
and participate in down-sizing efforts and • Caring/Respect
limitations of patient services, while • Beneficence
maintaining their moral responsibility?
 Rest’s Cognitive Process Model
Nursing Process
1) Interpretation
What is the perception that
• Assessment issues can affect the welfare
2) Sensitivities
What sensitivities
(feelings) are aroused by

• Diagnosis of someone else directly or

indirectly?
the ethical
interpretation?
• Planning What are the issues as What are the conflicting
defined by ethical principles? loyalties? What are the
• Intervention sensitive issues? How
are relationships affected?
• Evaluation 3) Possibilities 4) Action
Options for resolution? What action will be taken?

Ethical Decision-Making Process M.O.R.A.L. Model

(Aiken, 1994) (Crisham, 1992)

1. Collect, analyze, and interpret the data or information 1. Massage the dilemma
2. State the dilemma clearly 2. Outline the options / possibilities
3. Consider the choices of action based on ethical principles. 3. Review criteria and resolve
4. Analyze the advantages and disadvantages of each action.
4. Affirm the position
5. Make a decision that resolves the dilemma.
5. Look back