The Method to Arrive at an Ethical Decision

Maurice Bernstein, M.D. (moderator)

This presentation is based in part on a handout by Susan Rubin, Ph.D. and Laurie Zoloth, Ph.D. for a session at the 3rd Annual Meeting of the American Society for Bioethics and Humanities October 26,2000 titled "The Theory and Practice of Clinical Ethics: Charting a Course for Effective Consultation"

In a message dated 4/15/01 7:25:36 AM, raymond@bernett.per.sg wrote me the following: "What do you think are the questions that should come to mind when confronted with a ethical or moral question?"

Since I am involved in hospital ethics committee consultations what he requests is something which also must be of concern to me performing this activity. The questions he asks about are steps in a method for decision-making for ethical issues. Obviously, the method need not only be applied to clinical hospital ethical dilemmas and conflicts but can be used for many other bioethical issues. I wrote him back the following answer to his request:

1) What is the question? Define clearly the question or issue-We should make sure we understand exactly what is asked or what is the conflict.

2) What are the facts related to the question?- This is the most important element and often incompletely obtained.

3) What ethical or moral principles are involved? Consider:

Beneficence-the commitment to do good and promote well being

Nonmaleficience-the commitment to avoid or minimize harm

Autonomy-the commitment to respect the capacity and right of individuals to choose their own values and goals and to decide for themselves what happens to their body and their lives

Justice-the commitment to fairness, to giving each individual his due and to equitably allocate collective resources

Veracity-the commitment to truth telling

Fidelity-the commitment to promise keeping

Community- the commitment of taking into account the needs, interests, contribution and role of the community and acknowledging the way in which individuals are embedded to varous degrees in complicated relationships and broader connections which might not be readily apparent

4) What are the options? What are the answers or actions to take in order to resolve the question?

5) In order to resolve the ethical or moral question and selecting an option of action we must decide which principle, on balance, will result in the more good compared with competing principles. But in making this decision one must also consider the following concerns:

Consequences-the likely impact of each option on all parties involved

Rights-establishing whether basic rights are at stake and considering the correlative obligations

Duties-essential obligations we have for one another

Respect for Persons-value certain actions which lead to human flourishing and to value people who have the potential for such actions

Virtues-which include integrity, compassion, honesty and fidelity

Cost-Effectiveness and Justice-consideration of fairness to be taken into account in weighing the distribution and balance of the benefits and burdens of each option

6) Finally, the decision of the better option can be assisted by utilizing casuistry-Is this ethical question similar to one which a consensus has previously been obtained and therefore should we use that decision in the present question? Or the narrative approach-use of foundational stories to understand the nature of the ethical dilemma and the role and perspective of each stakeholder.

It is important to remember that the answer or option worked out by this method may not be final or absolute but may have to be revisited as time goes on and the facts change.