Personal morality Morality and Moral Values Societal morality

Group morality Decisions and Actions Rules and Codes Moral Principles Ethical Theories Moral Philosophy Teleological: the end justifies the means

Moral Philosophy

Deontological: the means need to be Deontological: the means need to be carefully weighed without primary concern carefully weighed without primary concern for the outcome for the outcome

Descriptive Ethics: Moral system of a group Descriptive Ethics: Moral system of a group or culture

or culture Ethical Theories Normative Ethics: Moral system used to Normative Ethics: Moral system used to make moral decisions make moral decisions

Bioethics: the application of ethics to health Bioethics: the application of ethics to health care care

Nonmaleficence Nonmaleficence

Beneficence Beneficence

Autonomy Autonomy Ethical Principles Justice Justice

Distributive Distributive

Compensatory (and retributive) Compensatory (and retributive)

Procedural Procedural

Fidelity: being faithful to one s clients, Fidelity: being faithful to one s clients, employer and colleagues employer and colleagues

Confidentiality (privacy): keeping nonConfidentiality (privacy): keeping nonrelevant information private relevant information private Rules and Codes Veracity: telling the truth; not lying Veracity: telling the truth; not lying

APTA Code of Ethics APTA Code of Ethics

FIU Student Code of Standards FIU Student Code of Standards Fundamentalism Fundamentalism: : the philosophical the philosophical stance that ethical stance that ethical principles are principles are universal universal

The Nature of Ethical Principles*

Multiculturalism Multiculturalism: : the anthropological the anthropological stance that ethical stance that ethical principles are

principles are culturally-bound culturally-bound

* Crigger NJ, Holcomb L, Weiss J. Fundamentalism, multiculturalism and problems of conducting research with populations in developing nations. Nursing Ethics. 2001;8(5)459468. Possible Cultural Differences* Individualism Individualism Autonomy Autonomy Individual liberty Individual liberty The individual The individual Individual rights Individual rights Individual development .. Individual development .. Contract Contract Self-determination Self-determination ... ... Communitarianism Communitarianism . Family decision-making . Family decision-making . . .. .. .. .. ... Social/common good ... Social/common good .. .. The collective The collective Personal virtues Personal virtues .. Family and filial piety .. Family and filial piety . . Trust Trust

... .. Self-examination ... .. Self-examination

Freedom Freedom

. Duty and obligation . Duty and obligation

*Nie J-B. The plurality of Chinese and American medical moralities: Toward an interpretive cross-cultural bioethics. Kennedy Institute of Ethics Journal. 2000;10(3):239-260. Porous social groups Porous social groups

Self-reliance and Self-reliance and individualism lead to individualism lead to valuing individual valuing individual autonomy autonomy

Informed consent & Informed consent & advanced directives advanced directives

Contrasting Norms, Cultural Beliefs and Values*

The individual as part

The individual as part of the larger whole of the larger whole values group cohesion values group cohesion

Group decides if Group decides if patient is told & what patient is told & what to do to do

Social groups resist Social groups resist outsiders outsiders * Davis AJ. Global influence of American nursing: some ethical issues. Nursing Ethics. 1999;6(2):118-125.

The Realm-Individual ProcessSituation (RIPS) Model of Ethical Decision Making A formalized approach to reflection and A formalized approach to reflection and

analysis of morality analysis of morality Step II: Reflect Step II: Reflect

Step I: Recognize and define the ethical Step I: Recognize and define the ethical issue (realm, individual process and issue (realm, individual process and situation) situation)

Four Step Process

Step III: Decide the right thing to do Step III: Decide the right thing to do

Step IV: Implement, evaluate and reassess Step IV: Implement, evaluate and reassess Components of the RIPS Model

Problem or issue Temptation Distress Dilemma

Silence

Moral Sensitivity Moral Judgment Moral Motivation Moral Courage Individual Institutional/ Organizational Societal Ethical Situation Individual Process Realm

Individual realm: concerned with the good of the Individual realm: concerned with the good of the patient/client and focuses on rights, duties, patient/client and focuses on rights, duties, relationships and behaviors between individuals relationships and behaviors between individuals Realm Institutional/organizational realm: concerned with Institutional/organizational realm: concerned with the good of the organization and focuses on

the good of the organization and focuses on structures and systems that will facilitate their structures and systems that will facilitate their goals goals

Societal realm: Societal realm:concerned with the common good concerned with the common good Moral judgment: deciding between right and Moral judgment: deciding between right and wrong actions; considering ethical principles wrong actions; considering ethical principles (autonomy, etc), then selecting and applying them (autonomy, etc), then selecting and applying them

Moral sensitivity: recognizing, interpreting and Moral sensitivity: recognizing, interpreting and framing ethical situations framing ethical situations

Individual Process

Moral motivation: prioritizing ethical values over Moral motivation: prioritizing ethical values over

financial gain or self-interest financial gain or self-interest

Moral courage: Moral courage:implementing the chosen ethical implementing the chosen ethical action, even though doing so may cause adversity action, even though doing so may cause adversity

Problem or issue: a situation in which important Problem or issue: a situation in which important moral values are being challenged moral values are being challenged

Temptation: a situation in which a choice must be Temptation: a situation in which a choice must be made between a right action and a wrong action, made between a right action and a wrong action, where the wrong action may benefit the decisionwhere the wrong action may benefit the decisionmaker in some way maker in some way Ethical Situation Silence: key parties realize ethical values are being

Silence: key parties realize ethical values are being challenged, but do nothing challenged, but do nothing

Distress Distress

Dilemma Dilemma

Ethical distress: there is a structural barrier Ethical distress: there is a structural barrier to doing the right thing to doing the right thing Ethical Distress Type A: There is a barrier keeping you from Type A: There is a barrier keeping you from doing what you know is right doing what you know is right

Type B: There is a barrier because something is Type B: There is a barrier because something is wrong, but you are not sure what that wrong, but you are not sure what that

something is something is You are doing something right, and also You are doing something right, and also something wrong. something wrong.

There are two (or more) correct courses of There are two (or more) correct courses of action that cannot both be followed. action that cannot both be followed.

Ethical Dilemma

Most often involve ethical conduct (e.g. Most often involve ethical conduct (e.g. honoring autonomy vs. preventing harm). honoring autonomy vs. preventing harm).

May involve conflicting traits of character May involve conflicting traits of character (e.g. honesty vs. compassion) (e.g. honesty vs. compassion) What are the potential consequences, intended or What are the potential consequences, intended or

unintended? unintended?

What are the relevant facts and contextual What are the relevant facts and contextual information? information?

Who are the major stakeholders? Who are the major stakeholders?

Step II: Reflect

What are the relevant laws, duties, and ethical What are the relevant laws, duties, and ethical principles? principles?

What professional guidance do we have? What professional guidance do we have?

What do the right vs. wrong tests suggest you What do the right vs. wrong tests suggest you should do? should do?

Right vs. Wrong The legal test: Did anyone do anything illegal? The legal test: Did anyone do anything illegal? The stench test : Does the situation smell wrong? The stench test : Does the situation smell wrong? Publicity (the front page test ): Would any of the parties Publicity (the front page test ): Would any of the parties involved be embarrassed by the truth coming out? involved be embarrassed by the truth coming out? Universality (the mom test ): What would your mom do? Universality (the mom test ): What would your mom do? Is this the right thing to do regardless of who s involved? Is this the right thing to do regardless of who s involved? The ethics test: Do the The ethics test: Do the Code of Ethics Code of Ethics, the , the Guide to Guide to Professional Conduct Professional Conduct, or , or Professionalism in Physical Professionalism in Physical Therapy: Core Values Therapy: Core Values, say anything about this situation? , say anything about this situation?

Locate the patient s individual beliefs Locate the patient s individual beliefs

Explicitly acknowledge patient s cultural norms, Explicitly acknowledge patient s cultural norms, beliefs and values beliefs and values

Cultural Issues

Be explicit about the process of decision-making Be explicit about the process of decision-making that generally guides your actions that generally guides your actions

Come to an agreement between all parties Come to an agreement between all parties (perhaps including the family) on what (perhaps including the family) on what information will be given and to whom. information will be given and to whom. Irvine R, McPhee J, Kerridge IH. The challenge of cultural and ethical pluralism to medical practice.MJA. 2002;176:175-176.

Rule-based: Follow only the principle you Rule-based: Follow only the principle you wantevery one else to follow wantevery one else to follow (deontological) (deontological) Step III: Decide What To Do Ends-based: Do whatever produces the Ends-based: Do whatever produces the greatest good for the greatest number greatest good for the greatest number (teleological) (teleological)

Care-based: Do onto others as you would Care-based: Do onto others as you would have them do onto you (the golden rule ) have them do onto you (the golden rule )