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Ethical
A practical approach to ethical decision-making
decision-making
Victor Maddalena
School of Health Services Administration, Dalhousie University, 71
Halifax, Canada

Abstract
Purpose – The purpose of this paper is to provide a practical approach to ethical decision-making for
executives working in the healthcare setting.
Design/methodology/approach – A nine step decision-making algorithm is presented to serve as a
guide for identifying and resolving complex ethical problems.
Findings – While decision-making frameworks are not new to the management literature, this
practical approach outlines a coherent and logical means by which executives can articulate a
management problem.
Originality/value – Identifies and evaluates potential solutions for consideration, plans an approach
to implementing the desired solution, and evaluates the impact of their decision.
Keywords Ethics, Decision making
Paper type General review

Introduction
Healthcare executives – in their private and public roles as leaders, mentors, and
teachers – often find their decisions scrutinized and their actions held to a higher
standard of conduct. As the delivery of health services becomes more complex, leaders
in health care are increasingly encountering difficult ethical dilemmas. Day-to-day
management (not to mention crisis management) of regionalized healthcare systems,
balancing competing interests for limited funds, priority-setting among apparently
equally beneficial programs and services, and managing public, professional and
political expectations provide ample decision-making challenges for governing boards,
healthcare executives, front-line managers and management teams.
Creating an organizational culture that promotes ethical decision-making is the
responsibility of the governing board and executive management team. Leading by
example requires that those in positions of authority and trust conduct themselves in a
manner that considers not only the immediate outcome of their decision, but also
whether the decision is congruent with organizational and social values. Moreover,
there is an emerging imperative for open and transparent decision-making and
accountability in health services administration and working in this new environment
can be a significant source of stress for managers (Ganster, 2005; Stanley, 2004).

This work was funded by a CIHR – NET: Palliative Care in Cross Cultural Context: A CIHR-NET
for Equitable and Quality Cancer Care for Culturally Diverse Populations and CIHR-ICE
“Interdisciplinary Capacity Enhancement (ICE) – Reducing Health Disparities and Promoting
Leadership in Health Services
Equity for Vulnerable Populations: Identification, Explication, and Applications of Research for Vol. 20 No. 2, 2007
Vulnerable Populations at End of Life”. The author wishes to thank Dr Jim Perkin for his pp. 71-75
q Emerald Group Publishing Limited
thoughtful critique of the manuscript. Special thanks to all the graduate students (too many to 1751-1879
name) who contributed to this endeavour. DOI 10.1108/17511870710745402
LHS Organizational crisis, characterized by an event that threatens the viability of an
20,2 organization and precipitated by a wide range of internal or external factors, (e,g,
inadequate funding, physical disaster, poor management, or personnel issues) can lead
to hurried, or ill-conceived decision-making that is often perceived as being unethical
(Christensen and Kohls, 2003). Resolution of a crisis situation requires thoughtful
deliberation, leadership skills and particular attention to ethical decision-making.
72 Ethics, or moral philosophy, has a distinct action-guiding aspect and is concerned
primarily with questions of right and wrong conduct and moral obligation (Pojman,
1998). While most decisions in health care have an ethical dimension, not all decisions
require the services of an ethics consultant or an institutional ethics committee to achieve
a satisfactory outcome. Typically, good decisions are the product of careful thought and
common sense and are grounded in accepted values and management practice.
At its most basic level, decision-making involves gathering information and
evaluating the merits and potential implications of each available option before
arriving at a decision. For routine management activities decision-making takes place
quickly and, with experience, becomes second nature and intuitive. Complex problems,
however, often require more time and resources, consultation with others,
consideration of various kinds of information, and a more thorough evaluation of
options and desired outcomes. Some decisions can have significant long term
implications for the organization, various stakeholders and successors.
Since 1997 I have invited successive years of graduate students in my “Ethics and
Decision-Making in Health Services Administration” course to work with me to
develop a methodological approach for resolving common administrative problems in
the healthcare setting. The basic framework started with the generic algorithm for all
decision-making: assess, plan, implement, and evaluate. Various management and
philosophical perspectives, thoughtful examination of case studies (and many lively
discussions) helped to develop and build on the basic algorithm.
The following practical approach to ethical decision-making can assist healthcare
executives, front-line managers or management teams in resolving complex
administrative problems. Governing boards, and ethics committees may also find
the nine step decision-making approach a useful structure to guide deliberations on
complex issues. It can also assist managers to identify the various dimensions of a
problem and articulate salient issues to prepare for a consultation with an institutional
ethics committee, or an external management or ethics consultant.

The decision-making process

Assess
1. State the problem(s). Clearly articulating the problem is often the most difficult part
of decision-making, yet it is an essential first step towards achieving resolution. Initial
perceptions of the problem may not be accurate and, depending on who is involved,
perceptions of the problem (causes and potential remedies) may vary. It can be a
significant challenge to identify, in a few words, the essence of the problem that is
under consideration.
2. Gather information.
.
Relevant facts. Identifying relevant facts in any problem situation can be a time
consuming process, yet establishing the facts is an essential step toward
resolution. Attempt to answer the following questions: What are the sources of
 information? Are these sources reliable? Separate fact from fiction and separate Ethical
opinion from fact. What are the various perceptions and interpretations of the decision-making
same information? And the critical, but often overlooked question: what
information is missing or not available? Identify those issues that are not
relevant to the problem. Is there a time constraint or deadline? Define the major
players and their roles.
.
Environmental scan. Issues or problems usually exist within a particular 73
geographic, political and/or historical context. In this step the objective is to
determine the environment within which the problem exists and identify the
significant factors (political, financial, human) that are influencing the problem
and limiting the possible solutions to be considered. What significant
relationships exist? Is there a “history” that needs to be considered? What
vested interests are at stake? Are there issues of power and privilege that need to
be taken into account?

3. Verify problem. Once the relevant facts have been determined and the problem has
been framed within a context, does the original assessment of the problem need to be
reconsidered? If so, why? If necessary, re-state the problem.
4. What is the best possible outcome?. Visualize and articulate the best possible
resolution. What would this look like? Is this outcome realistic given the current
environment, available resources and vested interests of the key stakeholders?

Plan
5. List all options. List and consider each available option. Have there been similar
cases that can be used as a guideline? If so, how were these situations resolved? Once
all the options have been identified assess the following: Who will benefit (or be
disadvantaged) by the decision? What are the possible outcomes of the decision in both
the short and long term? In other words, is this a “quick fix” or a long-term solution?
What are the potential costs and benefits of the decision (financial, human, political)?
6. Test each option.
.
Is it legal? What are the legal implications of the potential action(s) or
non-action(s) under consideration? By “legal” this includes municipal, provincial,
territorial and federal legislation and regulations, professional regulations and
standards, organizational by-laws and policy and, collective or legal agreements
with third parties for example with unions, insurers or suppliers.
.
Will it withstand public scrutiny? If the option was subjected to public scrutiny
would the decision be justifiable? Public scrutiny includes both agents and
groups external and internal to the organization. This is also known as the “light
of day” test, that is, what would happen if the decision was known to others
(Mallinger, 1997). Kidder (1994) refers to this as the “Front Page Test”, i.e. what
would happen if the decision made the front page of the morning paper?
Carefully consider the potential political or public relations and communications
implications?
.
Is it consistent with personal, professional, organizational and community values?
Ultimately, decisions-makers need to be able to justify their preferred course of
action to themselves and, more important, to others. What are the highest
LHS principles that apply to the problem under consideration (e.g. truth telling, “do no
20,2 harm”, adherence to principles of justice, beneficence)? Is adequate consideration
being given to the needs of those who are powerless or vulnerable? Consult with
professional Codes of Ethics, organizational mission and value statements to
determine if they are relevant to the problem. If the preferred option is not
compatible with the highest principles identified there may be difficulty
74 justifying this course of action.
.
Will the decision set a precedent? Will the decision set a precedent that will affect
future decisions, collective agreements, contracts, etc.? Will the decision set a
precedent that will affect third parties? Is there a need to consult with, or inform,
others who may be affected by the decision?

Implement.
7. Make a decision and implement. After gathering information and carefully
considering various options the ultimate test of a manager is to make a decision and
move forward with confidence. Of the options identified, rank them in order of
preference. Provide a justification for the preferred option. Clearly define the process by
which you will communicate this decision to others.

Evaluate
8. Define criteria for evaluation. This step is often overlooked in decision-making
processes. It is important to determine criteria that will be used to evaluate the outcome
of your decision. What evaluative criteria will be used to determine whether the right
decision has been made? Is the decision justifiable to those to whom the decision-maker
is responsible and accountable?
9. Resolution and follow-up. What has been learned from this event and how might a
similar situation or problem be prevented in the future? What lessons can be shared
with peers or colleagues? Is there a need to initiate a more formal review of the
situation or report the problem and its resolution to a third party or agency to ensure
due diligence?

Conclusion
Problem solving and decision-making skills are the basic tools of the healthcare
administrator. While most problems encountered in the workplace are resolved
without consciously referring to a decision-making framework, there are issues that
arise from time to time of a personal or professional nature that can challenge even the
most seasoned administrator or executive management team.
Competing public and political expectations, managing new technologies, and the
common conundrum of finding the balance between unlimited wants and limited
resources present myriad challenges for health care organizations. Applying a
coherent and practical approach to decision-making, such as the one proposed in this
article, can provide guidance for the identification and resolution of complex
administrative problems.

References
Christensen, S.L. and Kohls, J. (2003), “Ethical decision making in times of organizational crisis”,
Business and Society, Vol. 42 No. 3, p. 328.
Ganster, D.C. (2005), “Executive job demands: Suggestions from a stress and decision-making Ethical
perspective”, Academy of Management Review, Vol. 30 No. 3, p. 492.
Kidder, R.M. (1994), How Good People Make Tough Choices: Resolving Dilemmas of Ethical
decision-making
Living, Simon & Shuster, New York, NY.
Mallinger, M. (1997), “Decisive decision-making: an exercise using ethical frameworks”, Journal
of Management Education, Vol. 21 No. 3, pp. 411-7.
Pojman, L.P. (1998), Ethical Theory: Classical and Contemporary Readings, 3rd ed., Wadsworth 75
Publishing, Belmont, CA.
Stanley, T.L. (2004), “Stress management for high achievers”, SuperVision, Vol. 65 No. 3, p. 3.

About the author

Victor Maddalena is the former CEO of the Western Regional Health Board in Nova Scotia. He is
currently a CIHR-ICE Post-Doctoral Fellow “Interdisciplinary Capacity Enhancement (ICE) –
Reducing Health Disparities and Promoting Equity for Vulnerable Populations: Identification,
Explication, and Applications of Research for Vulnerable Populations at End-Of-Life” and an
Adjunct Professor in the School of Health Services Administration at Dalhousie University. He
teaches courses in Strategic Planning and Ethics and Decision-Making. He is the corresponding
author and can be contacted at: vjmaddal@dal.ca

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