ethical dilemma problem solving model

Ethical Decision Making Models and 6 Steps of Ethical Decision Making Process

By Andre Wyatt on March 21, 2023 — 10 minutes to read

In many ways, ethics may feel like a soft subject, a conversation that can wait when compared to other more seemingly pressing issues (a process for operations, hiring the right workers, and meeting company goals). However, putting ethics on the backburner can spell trouble for any organization. Much like the process of businesses creating the company mission, vision, and principles ; the topic of ethics has to enter the conversation. Ethics is far more than someone doing the right thing; it is many times tied to legal procedures and policies that if breached can put an organization in the midst of trouble.

• A general definition of business ethics is that it is a tool an organization uses to make sure that managers, employees, and senior leadership always act responsibly in the workplace with internal and external stakeholders.
• An ethical decision-making model is a framework that leaders use to bring these principles to the company and ensure they are followed.
• Importance of Ethical Standards Part 1
• Ethical Decision-Making Model Approach Part 2
• Ethical Decision-Making Process Part 3
• PLUS Ethical Decision-Making Model Part 4
• Character-Based Decision-Making Model Part 5

The Importance of Ethical Standards

Leaders have to develop ethical standards that employees in their company will be required to adhere to. This can help move the conversation toward using a model to decide when someone is in violation of ethics.

There are five sources of ethical standards:

Utilitarian

Common good.

While many of these standards were created by Greek Philosophers who lived long ago, business leaders are still using many of them to determine how they deal with ethical issues. Many of these standards can lead to a cohesive ethical decision-making model.

What is the purpose of an ethical decision-making model?

Ethical decision-making models are designed to help individuals and organizations make decisions in an ethical manner.

The purpose of an ethical decision-making model is to ensure that decisions are made in a manner that takes into account the ethical implications for all stakeholders involved.

Ethical decision-making models provide a framework for analyzing ethical dilemmas and serve as a guide for identifying potential solutions. By utilizing these models, businesses can ensure they are making decisions that align with their values while minimizing the risk of harming stakeholders. This can result in better decision-making and improved reputation.

Why is it important to use an ethical decision making model?

Making ethical decisions is an integral part of being a responsible leader and member of society. It is crucial to use an ethical decision making model to ensure that all stakeholders are taken into account and that decisions are made with the highest level of integrity. An ethical decision making model provides a framework for assessing the potential consequences of each choice, analyzing which option best aligns with personal values and organizational principles, and then acting on those conclusions.

An Empirical Approach to an Ethical Decision-Making Model

In 2011, a researcher at the University of Calgary in Calgary, Canada completed a study for the Journal of Business Ethics.

The research centered around an idea of rational egoism as a basis for developing ethics in the workplace.

She had 16 CEOs formulate principles for ethics through the combination of reasoning and intuition while forming and applying moral principles to an everyday circumstance where a question of ethics could be involved.

Through the process, the CEOs settled on a set of four principles:

• self-interest
• rationality

These were the general standards used by the CEOs in creating a decision about how they should deal with downsizing. While this is not a standard model, it does reveal the underlying ideas business leaders use to make ethical choices. These principles lead to standards that are used in ethical decision-making processes and moral frameworks.

How would you attempt to resolve a situation using an ethical decision-making model?

When facing a difficult situation, it can be beneficial to use an ethical decision-making model to help you come to the best possible solution. These models are based on the idea that you should consider the consequences of your decision, weigh the various options available, and consider the ethical implications of each choice. First, you should identify the problem or situation and clearly define what it is. Then, you must assess all of the possible outcomes of each choice and consider which one is most ethical. Once you have identified your preferred option, you should consult with others who may be affected by your decision to ensure that it aligns with their values and interests. You should evaluate the decision by considering how it affects yourself and others, as well as how it meets the expectations of your organization or institution.

The Ethical Decision-Making Process

Before a model can be utilized, leaders need to work through a set of steps to be sure they are bringing a comprehensive lens to handling ethical disputes or problems.

Take Time to Define the Problem

Consult resources and seek assistance, think about the lasting effects, consider regulations in other industries, decide on a decision, implement and evaluate.

While each situation may call for specific steps to come before others, this is a general process that leaders can use to approach ethical decision-making . We have talked about the approach; now it is time to discuss the lens that leaders can use to make the final decision that leads to implementation.

PLUS Ethical Decision-Making Model

PLUS Ethical Decision-Making Model is one of the most used and widely cited ethical models.

To create a clear and cohesive approach to implementing a solution to an ethical problem; the model is set in a way that it gives the leader “ ethical filters ” to make decisions.

It purposely leaves out anything related to making a profit so that leaders can focus on values instead of a potential impact on revenue.

The letters in PLUS each stand for a filter that leaders can use for decision-making:

• P – Policies and Procedures: Is the decision in line with the policies laid out by the company?
• L – Legal: Will this violate any legal parameters or regulations?
• U – Universal: How does this relate to the values and principles established for the organization to operate? Is it in tune with core values and the company culture?
• S – Self: Does it meet my standards of fairness and justice? This particular lens fits well with the virtue approach that is a part of the five common standards mentioned above.

These filters can even be applied to the process, so leaders have a clear ethical framework all along the way. Defining the problem automatically requires leaders to see if it is violating any of the PLUS ethical filters. It should also be used to assess the viability of any decisions that are being considered for implementation, and make a decision about whether the one that was chosen resolved the PLUS considerations questioned in the first step. No model is perfect, but this is a standard way to consider four vital components that have a substantial ethical impact .

The Character-Based Decision-Making Model

While this one is not as widely cited as the PLUS Model, it is still worth mentioning. The Character-Based Decision-Making Model was created by the Josephson Institute of Ethics, and it has three main components leaders can use to make an ethical decision.

• All decisions must take into account the impact to all stakeholders – This is very similar to the Utilitarian approach discussed earlier. This step seeks to do good for most, and hopefully avoid harming others.
• Ethics always takes priority over non-ethical values  – A decision should not be rationalized if it in any way violates ethical principles. In business, this can show up through deciding between increasing productivity or profit and keeping an employee’s best interest at heart.
• It is okay to violate another ethical principle if it advances a better ethical climate for others  – Leaders may find themselves in the unenviable position of having to prioritize ethical decisions. They may have to choose between competing ethical choices, and this model advises that leaders should always want the one that creates the most good for as many people as possible.

There are multiple components to consider when making an ethical decision. Regulations, policies and procedures, perception, public opinion, and even a leader’s morality play a part in how decisions that question business ethics should be handled. While no approach is perfect, a well-thought-out process and useful framework can make dealing with ethical situations easier.

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• The PLUS Ethical Decision Making Model

Seven Steps to Ethical Decision Making –  Step 1: Define the problem  (consult  PLUS filters ) –  Step 2: Seek out relevant assistance, guidance and support  –  Step 3: Identify alternatives –  Step 4: Evaluate the alternatives  (consult  PLUS filters ) –  Step 5: Make the decision –  Step 6: Implement the decision –  Step 7: Evaluate the decision  (consult  PLUS filters )

Introduction Organizations struggle to develop a simple set of guidelines that makes it easier for individual employees, regardless of position or level, to be confident that his/her decisions meet all of the competing standards for effective and ethical decision-making used by the organization. Such a model must take into account two realities:

• Every employee is called upon to make decisions in the normal course of doing his/her job. Organizations cannot function effectively if employees are not empowered to make decisions consistent with their positions and responsibilities.
• For the decision maker to be confident in the decision’s soundness, every decision should be tested against the organization’s policies and values, applicable laws and regulations as well as the individual employee’s definition of what is right, fair, good and acceptable.

The decision making process described below has been carefully constructed to be:

• Fundamentally sound based on current theories and understandings of both decision-making processes and ethics.
• Simple and straightforward enough to be easily integrated into every employee’s thought processes.
• Descriptive (detailing how ethical decision are made naturally) rather than prescriptive (defining unnatural ways of making choices).

Why do organizations need ethical decision making? See our special edition case study, #RespectAtWork, to find out.

First, explore the difference between what you expect and/or desire and the current reality. By defining the problem in terms of outcomes, you can clearly state the problem.

Consider this example: Tenants at an older office building are complaining that their employees are getting angry and frustrated because there is always a long delay getting an elevator to the lobby at rush hour. Many possible solutions exist, and all are predicated on a particular understanding the problem:

• Flexible hours – so all the tenants’ employees are not at the elevators at the same time.
• Faster elevators – so each elevator can carry more people in a given time period.
• Bigger elevators – so each elevator can carry more people per trip.
• Elevator banks – so each elevator only stops on certain floors, increasing efficiency.
• Better elevator controls – so each elevator is used more efficiently.
• More elevators – so that overall carrying capacity can be increased.
• Improved elevator maintenance – so each elevator is more efficient.
• Encourage employees to use the stairs – so fewer people use the elevators.

The real-life decision makers defined the problem as “people complaining about having to wait.” Their solution was to make the wait less frustrating by piping music into the elevator lobbies. The complaints stopped. There is no way that the eventual solution could have been reached if, for example, the problem had been defined as “too few elevators.”

How you define the problem determines where you go to look for alternatives/solutions– so define the problem carefully.

Step 2: Seek out relevant assistance, guidance and support

Once the problem is defined, it is critical to search out resources that may be of assistance in making the decision. Resources can include people (i.e., a mentor, coworkers, external colleagues, or friends and family) as well professional guidelines and organizational policies and codes. Such resources are critical for determining parameters, generating solutions, clarifying priorities and providing support, both while implementing the solution and dealing with the repercussions of the solution.

Step 3: Identify available alternative solutions to the problem The key to this step is to not limit yourself to obvious alternatives or merely what has worked in the past. Be open to new and better alternatives. Consider as many as solutions as possible — five or more in most cases, three at the barest minimum. This gets away from the trap of seeing “both sides of the situation” and limiting one’s alternatives to two opposing choices (i.e., either this or that).

Step 4: Evaluate the identified alternatives As you evaluate each alternative, identify the likely positive and negative consequence of each. It is unusual to find one alternative that would completely resolve the problem and is significantly better than all others. As you consider positive and negative consequences, you must be careful to differentiate between what you know for a fact and what you believe might be the case. Consulting resources, including written guidelines and standards, can help you ascertain which consequences are of greater (and lesser) import.

You should think through not just what results each alternative could yield, but the likelihood it is that such impact will occur. You will only have all the facts in simple cases. It is reasonable and usually even necessary to supplement the facts you have with realistic assumptions and informed beliefs. Nonetheless, keep in mind that the more the evaluation is fact-based, the more confident you can be that the expected outcome will occur. Knowing the ratio of fact-based evaluation versus non-fact-based evaluation allows you to gauge how confident you can be in the proposed impact of each alternative.

Step 5: Make the decision When acting alone, this is the natural next step after selecting the best alternative. When you are working in a team environment, this is where a proposal is made to the team, complete with a clear definition of the problem, a clear list of the alternatives that were considered and a clear rationale for the proposed solution.

Step 6: Implement the decision While this might seem obvious, it is necessary to make the point that deciding on the best alternative is not the same as doing something. The action itself is the first real, tangible step in changing the situation. It is not enough to think about it or talk about it or even decide to do it. A decision only counts when it is implemented. As Lou Gerstner (former CEO of IBM) said, “There are no more prizes for predicting rain. There are only prizes for building arks.”

Step 7: Evaluate the decision Every decision is intended to fix a problem. The final test of any decision is whether or not the problem was fixed. Did it go away? Did it change appreciably? Is it better now, or worse, or the same? What new problems did the solution create?

Ethics Filters

The ethical component of the decision making process takes the form of a set of “filters.” Their purpose is to surface the ethics considerations and implications of the decision at hand. When decisions are classified as being “business” decisions (rather than “ethics” issues), values can quickly be left out of consideration and ethical lapses can occur.

At key steps in the process, you should stop and work through these filters, ensuring that the ethics issues imbedded in the decision are given consideration.

We group the considerations into the mnemonic PLUS.

• P  = Policies Is it consistent with my organization’s policies, procedures and guidelines?
• L = Legal Is it acceptable under the applicable laws and regulations?
• U  = Universal Does it conform to the universal principles/values my organization has adopted?
• S = Self Does it satisfy my personal definition of right, good and fair?

The PLUS filters work as an integral part of steps 1, 4 and 7 of the decision-making process. The decision maker applies the four PLUS filters to determine if the ethical component(s) of the decision are being surfaced/addressed/satisfied.

• Does the existing situation violate any of the PLUS considerations?
• Step 2:   Seek out relevant assistance, guidance and support
• Step 3: Identify available alternative solutions to the problem
• Will the alternative I am considering resolve the PLUS violations?
• Will the alternative being considered create any new PLUS considerations?
• Are the ethical trade-offs acceptable?
• Step 5: Make the decision
• Step 6: Implement the decision
• Does the resultant situation resolve the earlier PLUS considerations?
• Are there any new PLUS considerations to be addressed?

The PLUS filters do not guarantee an ethically-sound decision. They merely ensure that the ethics components of the situation will be surfaced so that they might be considered.

How Organizations Can Support Ethical Decision-Making  Organizations empower employees with the knowledge and tools they need to make ethical decisions by

• Intentionally and regularly communicating to all employees:
• Organizational policies and procedures as they apply to the common workplace ethics issues.
• Applicable laws and regulations.
• Agreed-upon set of “universal” values (i.e., Empathy, Patience, Integrity, Courage [EPIC]).
• Providing a formal mechanism (i.e., a code and a helpline, giving employees access to a definitive interpretation of the policies, laws and universal values when they need additional guidance before making a decision).
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2.2: Three Frameworks for Ethical Problem-Solving in Business and the Professions

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• Page ID 20497

• William Frey and Jose a Cruz-Cruz
• University of Puerto Rico - Mayaguez

Module Introduction

In this module, you will learn and practice three frameworks designed to integrate ethics into decision making in the areas of practical and occupational ethics. The first framework divides the decision making process into four stages: problem specification, solution generation, solution testing, and solution implementation. It is based on an analogy between ethics and design problems that is detailed in a table presented below. The second framework focuses on the process of testing solution alternatives for their ethics by deploying three ethics tests that will help you to evaluate and rank alternative courses of action. The reversibility, harm, and publicity tests each "encapsulate" or summarize an important ethical theory. Finally, a feasibility test will help you to uncover interest, resource, and technical constraints that will affect and possibly impede the realization of your solution or decision. Taken together, these three frameworks will help steer you toward designing and implementing ethical solutions to problems in the professional and occupational areas.

Two online resources provide more extensive background information. The first, www.computingcases.org, provides background information on the ethics tests, socio-technical analysis, and intermediate moral concepts. The second, onlineethics.org/essays/educa.../teaching.html, explores in more detail the analogy between ethics and design problems. Much of this information will be published in Good Computing: A Virtue Approach to Computer Ethics, a textbook of cases and decision-making techniques in computer ethics that is being authored by Chuck Huff, William Frey, and Jose A. Cruz-Cruz.

Problem-Solving or Decision-Making Framework: Analogy between ethics and design

Traditionally, problem-solving frameworks in professional and occupational ethics have been taken from rational decision procedures used in economics. While these are useful, they lead one to think that ethical decisions are already "out there" waiting to be discovered. In contrast, taking a design approach to ethical decision making emphasizes that ethical decisions must be created, not discovered. This, in turn, emphasizes the importance of moral imagination and moral creativity. Carolyn Whitbeck in Ethics in Engineering Practice and Research describes this aspect of ethical decision making through the analogy she draws between ethics and design problems in chapter one. Here she rejects the idea that ethical problems are multiple-choice problems. We solve ethical problems not by choosing between ready-made solutions given with the situation; rather we use our moral creativity and moral imagination to design these solutions. Chuck Huff builds on this by modifying the design method used in software engineering so that it can help structure the process of framing ethical situations and creating actions to bring these situations to a successful and ethical conclusion. The key points in the analogy between ethical and design problems are summarized in the table presented just below.

Software Development Cycle: Four Stages

(1) problem specification, (2) solution generation, (3) solution testing, and (4) solution implementation.

Problem specification

Problem specification involves exercising moral imagination to specify the socio-technical system (including the stakeholders) that will influence and will be influenced by the decision we are about to make. Stating the problem clearly and concisely is essential to design problems; getting the problem right helps structure and channel the process of designing and implementing the solution. There is no algorithm available to crank out effective problem specification. Instead, we offer a series of guidelines or rules of thumb to get you started in a process that is accomplished by the skillful exercise of moral imagination.

For a broader problem framing model see Harris, Pritchard, and Rabins, Engineering Ethics: Concepts and Cases, 2nd Edition, Belmont, CA: Wadsworth, 2000, pp. 30-56. See also Cynthia Brincat and Victoria Wike, Morality and Professional Life: Values at Work, New Jersey: Prentice Hall, 1999.

Different Ways of Specifying the Problem

• Many problems can be specified as disagreements. For example, you disagree with your supervisor over the safety of the manufacturing environment. Disagreements over facts can be resolved by gathering more information. Disagreements over concepts (you and your supervisor have different ideas of what safety means) require working toward a common definition.
• Other problems involve conflicting values. You advocate installing pollution control technology because you value environmental quality and safety. Your supervisor resists this course of action because she values maintaining a solid profit margin. This is a conflict between a moral value (safety and environmental quality) and a nonmoral value (solid profits). Moral values can also conflict with one another in a given situation. Using John Doe lawsuits to force Internet Service Providers to reveal the real identities of defamers certainly protects the privacy and reputations of potential targets of defamation. But it also places restrictions on legitimate free speech by making it possible for powerful wrongdoers to intimidate those who would publicize their wrongdoing. Here the moral values of privacy and free speech are in conflict. Value conflicts can be addressed by harmonizing the conflicting values, compromising on conflicting values by partially realizing them, or setting one value aside while realizing the other (=value trade offs).
• If you specify your problem as a disagreement, you need to describe the facts or concepts about which there is disagreement.
• If you specify your problem as a conflict, you need to describe the values that conflict in the situation.
• One useful way of specifying a problem is to carry out a stakeholder analysis. A stakeholder is any group or individual that has a vital interest at risk in the situation. Stakeholder interests frequently come into conflict and solving these conflicts requires developing strategies to reconcile and realize the conflicting stakes.
• Another way of identifying and specifying problems is to carry out a socio-technical analysis. Socio-technical systems (STS) embody values. Problems can be anticipated and prevented by specifying possible value conflicts. Integrating a new technology, procedure, or policy into a socio-technical system can create three kinds of problem. (1) Conflict between values in the technology and those in the STS. For example, when an attempt is made to integrate an information system into the STS of a small business, the values present in an information system can conflict with those in the socio-technical system. (Workers may feel that the new information system invades their privacy.) (2) Amplification of existing value conflicts in the STS. The introduction of a new technology may magnify an existing value conflict. Digitalizing textbooks may undermine copyrights because digital media is easy to copy and disseminate on the Internet. (3) Harmful consequences. Introducing something new into a socio-technical system may set in motion a chain of events that will eventually harm stakeholders in the socio-technical system. For example, giving laptop computers to public school students may produce long term environmental harm when careless disposal of spent laptops releases toxic materials into the environment.
• The following table helps summarize some of these problem categories and then outlines generic solutions.

The materials on moral ecologies come from Huff, C., Barnard, L., and Frey, W. (2008). “Good computing: a pedagogically focused model of virtue in the practice of computing (parts 1 and 2)”, Journal of Information, Communication and Ethics in Society, Volume 6, Issues 3 and 4: 246-316. See also, Michael Davis, Thinking Like An Engineer, Oxford, 1998, 119-156.

Instructions for Using Problem Classification Table

• Is your problem a conflict? Moral versus moral value? Moral versus non-moral values? Non-moral versus non-moral values? Identify the conflicting values as concisely as possible. Example: In Toysmart, the financial values of creditors come into conflict with the privacy of individuals in the database: financial versus privacy values.
• Is your problem a disagreement? Is the disagreement over basic facts? Are these facts observable? Is it a disagreement over a basic concept? What is the concept? Is it a factual disagreement that, upon further reflection, changes into a conceptual disagreement?
• Does your problem arise from an impending harm? What is the harm? What is its magnitude? What is the probability that it will occur?
• If your problem is a value conflict then can these values be fully integrated in a value integrating solution? Or must they be partially realized in a compromise or traded off against one another?
• If your problem is a factual disagreement, what is the procedure for gathering the required information, if this is feasible?
• If your problem is a conceptual disagreement, how can this be overcome? By consulting a government policy or regulation? (OSHA on safety for example.) By consulting a theoretical account of the value in question? (Reading a philosophical analysis of privacy.) By collecting past cases that involve the same concept and drawing analogies and comparisons to the present case?

Moral Ecologies

• "Moral Ecology" refers to the organization in which one works. Calling this organization an "ecology" conveys the idea that it is a system of interrelated parts. These "ecologies" differ depending on the content of the organization's central, identity-conferring values.
• In finance-driven companies, financial values form the core of the organization's identity. Ethical advocacy requires skills in bringing ethical issues to the attention of decision-makers and getting them to take these issues seriously. It helps to state ethical concerns in multi-disciplinary language. (For example, show that ignoring ethical concerns will cost the company money in the long run.)
• Customer-driven ecologies place customer values like usability, affordability, and efficiency, in the forefront of group deliberation and decision-making. Often, one must play the role of "ethics advocate" in deliberation and decision-making. One is expected to argue forcefully and persistently ("go to the mat") to make sure that ethical considerations are integrated into group deliberations and decision-making.
• Quality-driven companies place ethical values into the core of group deliberations and decision-making. Here one is not so much ethics advocate as ethics enabler. This new role requires that one help one's group find creative ways of integrating ethical values with other concerns like customer and financial values.

If you are having problems specifying your problem

• Try identifying the stakeholders. Stakeholders are any group or individual with a vital interest at stake in the situation at hand.
• Project yourself imaginatively into the perspectives of each stakeholder. How does the situation look from their standpoint? What are their interests? How do they feel about their interests?
• Compare the results of these different imaginative projections. Do any stakeholder interests conflict? Do the stakeholders themselves stand in conflict?
• If the answer to one or both of these questions is "yes" then this is your problem statement. How does one reconcile conflicting stakeholders or conflicting stakeholder interests in this situation?

Framing Your Problem

• We miss solutions to problems because we choose to frame them in only one way.
• For example, the Mountain Terrorist Dilemma is usually framed in only one way: as a dilemma, that is, a forced decision between two equally undesirable alternatives. (Gilbane Gold is also framed as a dilemma: blow the whistle on Z-Corp or go along with the excess polution.)
• Framing a problem differently opens up new horizons of solution. Your requirement from this point on in the semester is to frame every problem you are assigned in at least two different ways.
• For examples of how to frame problems using socio-technical system analysis see module m14025.
• These different frames are summarized in the next box below.

Different Frames for Problems

• Technical Frame: Engineers frame problems technically, that is, they specify a problem as raising a technical issue and requiring a technical design for its resolution. For example, in the Hughes case, a technical frame would raise the problem of how to streamline the manufacturing and testing processes of the chips.
• Physical Frame: In the Laminating Press case, the physical frame would raise the problem of how the layout of the room could be changed to reduce the white powder. Would better ventilation eliminate or mitigate the white powder problem?
• Social Frame: In the "When in Aguadilla" case, the Japanese engineer is uncomfortable working with the Puerto Rican woman engineer because of social and cultural beliefs concerning women still widely held by men in Japan. Framing this as a social problem would involve asking whether there would be ways of getting the Japanese engineer to see things from the Puerto Rican point of view.
• Financial or Market-Based Frames: The DOE, in the Risk Assessment case below, accuses the laboratory and its engineers of trying to extend the contract to make more money. The supervisor of the head of the risk assessment team pressures the team leader to complete the risk assessment as quickly as possible so as not to lose the contract. These two framings highlight financial issues.
• Managerial Frame: As the leader of the Puerto Rican team in the "When in Aguadilla" case, you need to exercise leadership in your team. The refusal of the Japanese engineer to work with a member of your team creates a management problem. What would a good leader, a good manager, do in this situation? What does it mean to call this a management problem? What management strategies would help solve it?
• Legal Frame: OSHA may have clear regulations concerning the white powder produced by laminating presses. How can you find out about these regulations? What would be involved in complying with them? If they cost money, how would you get this money? These are questions that arise when you frame the Laminating Press case as a legal problem.
• Environmental Framing: Finally, viewing your problem from an environmental frame leads you to consider the impact of your decision on the environment. Does it harm the environment? Can this harm be avoided? Can it be mitigated? Can it be offset? (Could you replant elsewhere the trees you cut down to build your new plant?) Could you develop a short term environmental solution to "buy time" for designing and implementing a longer term solution? Framing your problem as an environmental problem requires that you ask whether this solution harms the environment and whether this harming can be avoided or remedied in some other way.

Solution Generation

In solution generation, agents exercise moral creativity by brainstorming to come up with solution options designed to resolve the disagreements and value conflicts identified in the problem specification stage. Brainstorming is crucial to generating nonobvious solutions to difficult, intractable problems. This process must take place within a non-polarized environment where the members of the group respect and trust one another. (See the module on the Ethics of Group Work for more information on how groups can be successful and pitfalls that commonly trip up groups.) Groups effectively initiate the brainstorming process by suspending criticism and analysis. After the process is completed (say, by meeting a quota), then participants can refine the solutions generated by combining them, eliminating those that don't fit the problem, and ranking them in terms of their ethics and feasibility. If a problem can't be solved, perhaps it can be dissolved through reformulation. If an entire problem can't be solved, perhaps the problem can be broken down into parts some of which can be readily solved.

Having trouble generating solutions?

• One of the most difficult stages in problem-solving is to jump-start the process of brainstorming solutions. If you are stuck then here are some generic options guaranteed to get you "unstuck."
• Gather Information: Many disagreements can be resolved by gathering more information. Because this is the easiest and least painful way of reaching consensus, it is almost always best to start here. Gathering information may not be possible because of different constraints: there may not be enough time, the facts may be too expensive to gather, or the information required goes beyond scientific or technical knowledge. Sometimes gathering more information does not solve the problem but allows for a new, more fruitful formulation of the problem. Harris, Pritchard, and Rabins in Engineering Ethics: Concepts and Cases show how solving a factual disagreement allows a more profound conceptual disagreement to emerge.
• Nolo Contendere. Nolo Contendere is Latin for not opposing or contending. Your interests may conflict with your supervisor but he or she may be too powerful to reason with or oppose. So your only choice here is to give in to his or her interests. The problem with nolo contendere is that non-opposition is often taken as agreement. You may need to document (e.g., through memos) that your choosing not to oppose does not indicate agreement.
• Negotiate. Good communication and diplomatic skills may make it possible to negotiate a solution that respects the different interests. Value integrative solutions are designed to integrate conflicting values. Compromises allow for partial realization of the conflicting interests. (See the module, The Ethics of Team Work, for compromise strategies such as logrolling or bridging.) Sometimes it may be necessary to set aside one's interests for the present with the understanding that these will be taken care of at a later time. This requires trust.
• Oppose. If nolo contendere and negotiation are not possible, then opposition may be necessary. Opposition requires marshaling evidence to document one's position persuasively and impartially. It makes use of strategies such as leading an "organizational charge" or "blowing the whistle." For more on whistle-blowing consult the discussion of whistleblowing in the Hughes case that can be found in computing cases.
• Exit. Opposition may not be possible if one lacks organizational power or documented evidence. Nolo contendere will not suffice if non-opposition implicates one in wrongdoing. Negotiation will not succeed without a necessary basis of trust or a serious value integrative solution. As a last resort, one may have to exit from the situation by asking for reassignment or resigning.

Refining solutions

• Are any solutions blatantly unethical or unrealizable?
• Do any solutions overlap? Can these be integrated into broader solutions?
• Can solutions be brought together as courses of action that can be pursued simultaneously?
• Go back to the problem specification? Can any solutions be eliminated because they do not address the problem? (Or can the problem be revised to better fit what, intuitively, is a good solution.)
• Can solutions be brought together as successive courses of action? For example, one solution represents Plan A; if it does not work then another solution, Plan B, can be pursued. (You negotiate the problem with your supervisor. If she fails to agree, then you oppose your supervisor on the grounds that her position is wrong. If this fails, you conform or exit.)
• The goal here is to reduce the solution list to something manageable, say, a best, a second best, and a third best. Try adding a bad solution to heighten strategic points of comparison. The list should be short so that the remaining solutions can be intensively examined as to their ethics and feasibility.

Solution Testing: The solutions developed in the second stage must be tested in various ways.

• Reversibility: Would I still think the choice of this option good if I were one of those adversely affected by it? (Davis uses this formulation in various publications.) I identify different stakeholders and then take up their roles. Through this imaginative projection, I should consider how the action under consideration will affect them and how they will view, interpret, and experience this affect.
• Harm: Does this option do less harm than any available alternative? Here I try to design an action that will minimize harmful effects. I should factor in the likely results of the action under consideration but I should also evaluate how justly these results will be distributed among stakeholders.
• Publicity: What kind of person will I become if I choose this action? This is Davis' formulation of this test as a virtue test. The key to this test is that you associate the agent with the action. If I (the agent) am publicly judged as a person in terms of this action, what does this say about me as a person? Am I comfortable being judged an irresponsible person on the basis of my being identified with my irresponsible action?
• Meta-Test - Convergence: Do a quick inventory here. Do the ethics tests come together and agree on ranking this solution as a strong one? Then this solution satisfies the convergence meta-test and this provides independent evidence of the strength of the solution.
• Meta-Test - Divergence: Again, do a quick inventory of your solution evaluation matrix results to this point. Do the tests differ or diverge on this point? This is independent evidence of the weakness of this solution. Think about why this solution may be strong under one test but weak under the others.
• The solution evaluation matrix presented just below models and summarizes the solution testing process.

Solution Implementation

The chosen solution must be examined in terms of how well it responds to various situational constraints that could impede its implementation. What will be its costs? Can it be implemented within necessary time constraints? Does it honor recognized technical limitations or does it require pushing these back through innovation and discovery? Does it comply with legal and regulatory requirements? Finally, could the surrounding organizational, political, and social environments give rise to obstacles to the implementation of the solution? In general this phase requires looking at interest, technical, and resource constraints or limitations. A Feasibility Matrix helps to guide this process.

The Feasibility Tests focuses on situational constraints. How could these hinder the implementation of the solution? Should the solution be modified to ease implementation? Can the constraints be removed or remodeled by negotiation, compromise, or education? Can implementation be facilitated by modifying both the solution and changing the constraints?

Different Feasibility Constraints

• The Feasibility Test identifies the constraints that could interfere with realizing a solution. This test also sorts out these constraints into resource (time, cost, materials), interest (individuals, organizations, legal, social, political), and technical limitations. By identifying situational constraints, problem-solvers can anticipate implementation problems and take early steps to prevent or mitigate them.
• Time. Is there a deadline within which the solution has to be enacted? Is this deadline fixed or negotiable?
• Financial. Are there cost constraints on implementing the ethical solution? Can these be extended by raising more funds? Can they be extended by cutting existing costs? Can agents negotiate for more money for implementation?
• Technical. Technical limits constrain the ability to implement solutions. What, then, are the technical limitations to realizing and implementing the solution? Could these be moved back by modifying the solution or by adopting new technologies?
• Manufacturability. Are there manufacturing constraints on the solution at hand? Given time, cost, and technical feasibility, what are the manufacturing limits to implementing the solution? Once again, are these limits fixed or flexible, rigid or negotiable?
• Legal. How does the proposed solution stand with respect to existing laws, legal structures, and regulations? Does it create disposal problems addressed in existing regulations? Does it respond to and minimize the possibility of adverse legal action? Are there legal constraints that go against the ethical values embodied in the solution? Again, are these legal constraints fixed or negotiable?
• Individual Interest Constraints. Individuals with conflicting interests may oppose the implementation of the solution. For example, an insecure supervisor may oppose the solution because he fears it will undermine his authority. Are these individual interest constraints fixed or negotiable?
• Organizational. Inconsistencies between the solution and the formal or informal rules of an organization may give rise to implementation obstacles. Implementing the solution may require support of those higher up in the management hierarchy. The solution may conflict with organization rules, management structures, traditions, or financial objectives. Once again, are these constraints fixed or flexible?
• Social, Cultural, or Political. The socio-technical system within which the solution is to be implemented contains certain social structures, cultural traditions, and political ideologies. How do these stand with respect to the solution? For example, does a climate of suspicion of high technology threaten to create political opposition to the solution? What kinds of social, cultural, or political problems could arise? Are these fixed or can they be altered through negotiation, education, or persuasion?

Ethics Tests For Solution Evaluation

Three ethics tests (reversibility, harm/beneficence, and public identification) encapsulate three ethical approaches (deontology, utilitarianism, and virtue ethics) and form the basis of stage three of the SDC, solution testing. A fourth test (a value realization test) builds upon the public identification/virtue ethics test by evaluating a solution in terms of the values it harmonizes, promotes, protects, or realizes. Finally a code test provides an independent check on the ethics tests and also highlights intermediate moral concepts such as safety, health, welfare, faithful agency, conflict of interest, confidentiality, professional integrity, collegiality, privacy, property, free speech, and equity/access). The following section provides advice on how to use these tests. More information can be found at www.computingcases.org.

Setting Up the Ethics Tests: Pitfalls to avoid

Set-Up Pitfalls: Mistakes in this area lead to the analysis becoming unfocused and getting lost in irrelevancies. (a) Agent-switching where the analysis falls prey to irrelevancies that crop up when the test application is not grounded in the standpoint of a single agent, (b) Sloppy action-description where the analysis fails because no specific action has been tested, (c) Test-switching where the analysis fails because one test is substituted for another. (For example, the public identification and reversibility tests are often reduced to the harm/beneficence test where harmful consequences are listed but not associated with the agent or stakeholders.)

Set up the test

• Identify the agent (the person who is going to perform the action)
• Describe the action or solution that is being tested (what the agent is going to do or perform)
• Identify the stakeholders (those individuals or groups who are going to be affected by the action), and their stakes (interests, values, goods, rights, needs, etc.
• Identify, sort out, and weigh the consequences (the results the action is likely to bring about)

Harm/Beneficence Test

• What harms would accompany the action under consideration? Would it produce physical or mental suffering, impose financial or non-financial costs, or deprive others of important or essential goods?
• What benefits would this action bring about? Would it increase safety, quality of life, health, security, or other goods both moral and non-moral?
• What is the magnitude of each these consequences? Magnitude includes likelihood it will occur (probability), the severity of its impact (minor or major harm) and the range of people affected.
• Identify one or two other viable alternatives and repeat these steps for them. Some of these may be modifications of the basic action that attempt to minimize some of the likely harms. These alternatives will establish a basis for assessing your alternative by comparing it with others.
• Decide on the basis of the test which alternative produces the best ratio of benefits to harms?
• Check for inequities in the distribution of harms and benefits. Do all the harms fall on one individual (or group)? Do all of the benefits fall on another? If harms and benefits are inequitably distributed, can they be redistributed? What is the impact of redistribution on the original solution imposed?

Pitfalls of the Harm/Beneficence Test

• “Paralysis of Analysis" comes from considering too many consequences and not focusing only on those relevant to your decision.
• Incomplete Analysis results from considering too few consequences. Often it indicates a failure of moral imagination which, in this case, is the ability to envision the consequences of each action alternative.
• Failure to compare different alternatives can lead to a decision that is too limited and one-sided.
• Failure to weigh harms against benefits occurs when decision-makers lack the experience to make the qualitative comparisons required in ethical decision making.
• Finally, justice failures result from ignoring the fairness of the distribution of harms and benefits. This leads to a solution which may maximize benefits and minimize harms but still give rise to serious injustices in the distribution of these benefits and harms.

Reversibility Test

• Set up the test by (i) identifying the agent, (ii) describing the action, and (iii) identifying the stakeholders and their stakes.
• Use the stakeholder analysis to identify the relations to be reversed.
• Reverse roles between the agent (you) and each stakeholder: put them in your place (as the agent) and yourself in their place (as the one subjected to the action).
• If you were in their place, would you still find the action acceptable?

Cross Checks for Reversibility Test (These questions help you to check if you have carried out the reversibility test properly.)

• Does the proposed action treat others with respect? (Does it recognize their autonomy or circumvent it?)
• Does the action violate the rights of others? (Examples of rights: free and informed consent, privacy, freedom of conscience, due process, property, freedom of expression)
• Would you recommend that this action become a universal rule?
• Are you, through your action, treating others merely as means?

Pitfalls of the Reversibility Test

• Leaving out a key stakeholder relation
• Failing to recognize and address conflicts between stakeholders and their conflicting stakes
• Confusing treating others with respect with capitulating to their demands (“Reversing with Hitler”)
• Failing to reach closure, i.e., an overall, global reversal assessment that takes into account all the stakeholders the agent has reversed with.

Steps in Applying the Public Identification Test

• Set up the analysis by identifying the agent, describing the action, and listing the key values or virtues at play in the situation.
• Association the action with the agent.
• Describe what the action says about the agent as a person. Does it reveal him or her as someone associated with a virtue or a vice?

Alternative Version of Public Identification

• Does the action under consideration realize justice or does it pose an excess or defect of justice?
• Does the action realize responsibility or pose an excess or defect of responsibility?
• Does the action realize reasonableness or pose too much or too little reasonableness?
• Does the action realize honesty or pose too much or too little honesty?
• Does the action realize integrity or pose too much or too little integrity?

Pitfalls of Public Identification

• Action not associated with agent. The most common pitfall is failure to associate the agent and the action. The action may have bad consequences and it may treat individuals with respect but these points are not as important in the context of this test as what they imply about the agent as a person who deliberately performs such an action.
• Failure to specify moral quality, virtue, or value. Another pitfall is to associate the action and agent but only ascribe a vague or ambiguous moral quality to the agent. To say, for example, that willfully harming the public is bad fails to zero in on precisely what moral quality this ascribes to the agent. Does it render him or her unjust, irresponsible, corrupt, dishonest, or unreasonable? The virtue list given above will help to specify this moral quality.

Code of Ethics Test

• Does the action hold paramount the health, safety, and welfare of the public, i.e., those affected by the action but not able to participate in its design or execution?
• Does the action maintain faithful agency with the client by not abusing trust, avoiding conflicts of interest, and maintaining confidences?
• Is the action consistent with the reputation, honor, dignity, and integrity of the profession?
• Does the action serve to maintain collegial relations with professional peers?
• The ethics and feasibility tests will not always converge on the same solution. There is a complicated answer for why this is the case but the simple version is that the tests do not always agree on a given solution because each test (and the ethical theory it encapsulates) covers a different domain or dimension of the action situation. Meta tests turn this disadvantage to your advantage by feeding the interaction between the tests on a given solution back into the evaluation of that solution.
• When the ethics tests converge on a given solution, this convergence is a sign of the strength and robustness of the solution and counts in its favor.
• When a given solution responds well to one test but does poorly under another, this is a sign that the solution needs further development and revision. It is not a sign that one test is relevant while the others are not. Divergence between test results is a sign that the solution is weak.

Application Exercise

You will now practice the four stages of decision making with a real-world case. This case, Risk Assessment, came from a retreat on Business, Science, and Engineering Ethics held in Puerto Rico in December 1998. It was funded by the National Science Foundation, Grant SBR 9810253.

Risk Assessment ScenarioCase Scenario: You supervise a group of engineers working for a private laboratory with expertise in nuclear waste disposal and risk assessment. The DOE (Department of Energy) awarded a contract to your laboratory six years ago to do a risk assessment of various nuclear waste disposal sites. During the six years in which your team has been doing the study, new and more accurate calculations in risk assessment have become available. Your laboratory’s study, however, began with the older, simpler calculations and cannot integrate the newer without substantially delaying completion. You, as the leader of the team, propose a delay to the DOE on the grounds that it is necessary to use the more advanced calculations. Your position is that the laboratory needs more time because of the extensive calculations required; you argue that your group must use state of the art science in doing its risk assessment. The DOE says you are using overly high standards of risk assessment to prolong the process, extend the contract, and get more money for your company. They want you to use simpler calculations and finish the project; if you are unwilling to do so, they plan to find another company that thinks differently. Meanwhile, back at the laboratory, your supervisor (a high level company manager) expresses to you the concern that while good science is important in an academic setting, this is the real world and the contract with the DOE is in jeopardy. What should you do?

Part One: Problem Specification

• Specify the problem in the above scenario. Be as concise and specific as possible
• Is your problem best specifiable as a disagreement? Between whom? Over what?
• Can your problem be specified as a value conflict? What are the values in conflict? Are the moral, nonmoral, or both?

Part Two: Solution Generation

• Quickly and without analysis or criticism brainstorm 5 to ten solutions
• Refine your solution list. Can solutions be eliminated? (On what basis?) Can solutions be combined? Can solutions be combined as plan a and plan b?
• If you specified your problem as a disagreement, how do your solutions resolve the disagreement? Can you negotiate interests over positions? What if your plan of action doesn't work?
• If you formulated your problem as a value conflict, how do your solutions resolve this conflict? By integrating the conflicting values? By partially realizing them through a value compromise? By trading one value off for another?

Part Three: Solution Testing

• Construct a solution evaluation matrix to compare two to three solution alternatives.
• Choose a bad solution and then compare to it the two strongest solutions you have.
• Be sure to avoid the pitfalls described above and set up each test carefully.

Part Four: Solution Implementation

• Develop an implementation plan for your best solution. This plan should anticipate obstacles and offer means for overcoming them.
• Prepare a feasibility table outlining these issues using the table presented above.
• Remember that each of these feasibility constraints is negotiable and therefore flexible. If you choose to set aside a feasibility constraint then you need to outline how you would negotiate the extension of that constraint.

Decision-Making Presentation

Problem Solving Presentation

Shortened Presentation for Fall 2012

Vigo Socio-Technical System Table and Problems

Test Rubric Fall 2009: Problem-Solving

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6.3 Ethical Dilemmas

Nurses frequently find themselves involved in conflicts during patient care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.

An ethical dilemma can involve conflicting patient’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.

Table 6.3a Examples of Ethical Issues Involving Nurses

Read more about Ethics Topics and Articles on the ANA website.

According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors [1] :

• Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
• An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements [2]
• Knowledge of ethical principles and their application to ethical decision-making
• Motivation and skills to implement an ethical decision

Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.” [3] See Figure 6.7 [4] for an illustration of nurses’ moral courage.

Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up. [5] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during patient care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.

Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations. [6] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs. [7]  Read more about self-care strategies to address feelings of burnout in the “ Burnout and Self-Care ” chapter.

Frameworks for Solving Ethical Dilemmas

Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model. [8] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.

Nursing Process Model

The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma. [9]

Table 6.3b Using the Nursing Process in Ethical Situations [10]

Four-Quadrant Approach

The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features. [11] See Table 6.3c for sample questions used during the four-quadrant approach.

Table 6.3c Four-Quadrant Approach [12]

MORAL Model

The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model. [13] , [14]

Table 6.3d MORAL Model

PLUS Ethical Decision-Making Model

The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:

• P: Policies, procedures, and guidelines of an organization
• L: Laws and regulations
• U: Universal values and principles of an organization
• S: Self-identification of what is good, right, fair, and equitable [15]

The seven steps of the PLUS Ethical Decision-Making model are as follows [16] :

• Define the problem using PLUS filters
• Seek relevant assistance, guidance, and support
• Identify available alternatives
• Evaluate the alternatives using PLUS to identify their impact
• Make the decision
• Implement the decision
• Evaluate the decision using PLUS filters
• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
• American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only / ↵
• American Nurses Association (ANA). Ethics topics and articles. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ethics-topics-and-articles/ ↵
• “Moral courage.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵
• Norman, S. & Maguen, S. (n.d.). Moral injury. PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp ↵
• Dean, W., Jacobs, B., & Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. Annals of Emergency Medicine, 76 (4), 385–386. https://doi.org/10.1016/j.annemergmed.2020.05.023 ↵
• Crisham, P. (1985). Moral: How can I do what is right? Nursing Management, 16 (3), 44. https://journals.lww.com/nursingmanagement/citation/1985/03000/moral__how_can_i_do_what_s_right_.6.aspx ↵
• Ethics & Compliance Initiative. (2021). The PLUS Ethical Decision Making Model . https://www.ethics.org/resources/free-toolkit/decision-making-model/ ↵

Conflict resulting from competing values that requires a decision to be made from equally desirable or undesirable options.

The willingness of an individual to speak out and do what is right in the face of forces that would lead us to act in some other way.

Feelings occurring when an individual is uncertain about what values or principles should be applied to an ethical issue.

Feelings occurring when correct ethical action is identified but the individual feels constrained by competing values of an organization or other individuals.

Feelings occurring when an individual witnesses immoral acts or practices they feel powerless to change.

Distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Thinking Ethically

• Markkula Center for Applied Ethics
• Ethics Resources
• Ethical Decision Making

Moral issues greet us each morning in the newspaper, confront us in the memos on our desks, nag us from our children's soccer fields, and bid us good night on the evening news. We are bombarded daily with questions about the justice of our foreign policy, the morality of medical technologies that can prolong our lives, the rights of the homeless, the fairness of our children's teachers to the diverse students in their classrooms.

Dealing with these moral issues is often perplexing. How, exactly, should we think through an ethical issue? What questions should we ask? What factors should we consider?

The first step in analyzing moral issues is obvious but not always easy: Get the facts. Some moral issues create controversies simply because we do not bother to check the facts. This first step, although obvious, is also among the most important and the most frequently overlooked.

But having the facts is not enough. Facts by themselves only tell us what is ; they do not tell us what ought to be. In addition to getting the facts, resolving an ethical issue also requires an appeal to values. Philosophers have developed five different approaches to values to deal with moral issues.

The Utilitarian Approach Utilitarianism was conceived in the 19th century by Jeremy Bentham and John Stuart Mill to help legislators determine which laws were morally best. Both Bentham and Mill suggested that ethical actions are those that provide the greatest balance of good over evil.

To analyze an issue using the utilitarian approach, we first identify the various courses of action available to us. Second, we ask who will be affected by each action and what benefits or harms will be derived from each. And third, we choose the action that will produce the greatest benefits and the least harm. The ethical action is the one that provides the greatest good for the greatest number.

The Rights Approach The second important approach to ethics has its roots in the philosophy of the 18th-century thinker Immanuel Kant and others like him, who focused on the individual's right to choose for herself or himself. According to these philosophers, what makes human beings different from mere things is that people have dignity based on their ability to choose freely what they will do with their lives, and they have a fundamental moral right to have these choices respected. People are not objects to be manipulated; it is a violation of human dignity to use people in ways they do not freely choose.

Of course, many different, but related, rights exist besides this basic one. These other rights (an incomplete list below) can be thought of as different aspects of the basic right to be treated as we choose.

The right to the truth: We have a right to be told the truth and to be informed about matters that significantly affect our choices.

The right of privacy: We have the right to do, believe, and say whatever we choose in our personal lives so long as we do not violate the rights of others.

The right not to be injured: We have the right not to be harmed or injured unless we freely and knowingly do something to deserve punishment or we freely and knowingly choose to risk such injuries.

The right to what is agreed: We have a right to what has been promised by those with whom we have freely entered into a contract or agreement.

In deciding whether an action is moral or immoral using this second approach, then, we must ask, Does the action respect the moral rights of everyone? Actions are wrong to the extent that they violate the rights of individuals; the more serious the violation, the more wrongful the action.

The Fairness or Justice Approach The fairness or justice approach to ethics has its roots in the teachings of the ancient Greek philosopher Aristotle, who said that "equals should be treated equally and unequals unequally." The basic moral question in this approach is: How fair is an action? Does it treat everyone in the same way, or does it show favoritism and discrimination?

Favoritism gives benefits to some people without a justifiable reason for singling them out; discrimination imposes burdens on people who are no different from those on whom burdens are not imposed. Both favoritism and discrimination are unjust and wrong.

The Common-Good Approach This approach to ethics assumes a society comprising individuals whose own good is inextricably linked to the good of the community. Community members are bound by the pursuit of common values and goals.

The common good is a notion that originated more than 2,000 years ago in the writings of Plato, Aristotle, and Cicero. More recently, contemporary ethicist John Rawls defined the common good as "certain general conditions that are...equally to everyone's advantage."

In this approach, we focus on ensuring that the social policies, social systems, institutions, and environments on which we depend are beneficial to all. Examples of goods common to all include affordable health care, effective public safety, peace among nations, a just legal system, and an unpolluted environment.

Appeals to the common good urge us to view ourselves as members of the same community, reflecting on broad questions concerning the kind of society we want to become and how we are to achieve that society. While respecting and valuing the freedom of individuals to pursue their own goals, the common-good approach challenges us also to recognize and further those goals we share in common.

The Virtue Approach The virtue approach to ethics assumes that there are certain ideals toward which we should strive, which provide for the full development of our humanity. These ideals are discovered through thoughtful reflection on what kind of people we have the potential to become.

Virtues are attitudes or character traits that enable us to be and to act in ways that develop our highest potential. They enable us to pursue the ideals we have adopted. Honesty, courage, compassion, generosity, fidelity, integrity, fairness, self-control, and prudence are all examples of virtues.

Virtues are like habits; that is, once acquired, they become characteristic of a person. Moreover, a person who has developed virtues will be naturally disposed to act in ways consistent with moral principles. The virtuous person is the ethical person.

In dealing with an ethical problem using the virtue approach, we might ask, What kind of person should I be? What will promote the development of character within myself and my community?

Ethical Problem Solving These five approaches suggest that once we have ascertained the facts, we should ask ourselves five questions when trying to resolve a moral issue:

What benefits and what harms will each course of action produce, and which alternative will lead to the best overall consequences?

What moral rights do the affected parties have, and which course of action best respects those rights?

Which course of action treats everyone the same, except where there is a morally justifiable reason not to, and does not show favoritism or discrimination?

Which course of action advances the common good?

Which course of action develops moral virtues?

This method, of course, does not provide an automatic solution to moral problems. It is not meant to. The method is merely meant to help identify most of the important ethical considerations. In the end, we must deliberate on moral issues for ourselves, keeping a careful eye on both the facts and on the ethical considerations involved.

This article updates several previous pieces from Issues in Ethics by Manuel Velasquez - Dirksen Professor of Business Ethics at Santa Clara University and former Center director - and Claire Andre, associate Center director. "Thinking Ethically" is based on a framework developed by the authors in collaboration with Center Director Thomas Shanks, S.J., Presidential Professor of Ethics and the Common Good Michael J. Meyer, and others. The framework is used as the basis for many programs and presentations at the Markkula Center for Applied Ethics.

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Scher S, Kozlowska K. Rethinking Health Care Ethics [Internet]. Singapore: Palgrave Pivot; 2018. doi: 10.1007/978-981-13-0830-7_5

Rethinking Health Care Ethics [Internet].

Chapter 5 the elusiveness of closure.

Published online: August 3, 2018.

Unlike what happens in the classroom, where discussions can end in conflict, with agreement nowhere in sight, ethical problems in clinical health care require that decisions be made. Some form of closure is required in order to move forward. And closure can be elusive indeed. In this chapter we look at efforts to achieve closure through the use of multistep processes, as proposed by some bioethicists.

In clinical practice, ethical problems do not arise out of nowhere. They develop, over time, from preexisting, but evolving, clinical situations. We start this chapter with a vignette adapted from the clinical experience of the second author (KK).

• Vignette: A Morbidly Obese, Developmentally Delayed 14-Year-Old

A family presents with a 150-kilogram (330-pound), epileptic, developmentally delayed, violent 14-year-old boy with a genetically related dementing illness. He had recently started refusing to leave home, with the consequence that he has not been attending school. At the observational admission, the clinical situation is assessed by the full range of health professionals at the hospital. Particular problems are identified as amenable to intervention, and both staff and family members are given various follow-up tasks to complete, including the following: a trial of different medications; provision of respite services for the parents; organization of services to assist in transporting the child to school on a regular basis; further review of the boy’s behavior-management program; and an assessment of the mother’s and possibly father’s mental and physical health.

Over the course of the next year, the father’s increasing stress about the situation at home led him to withdraw from the family, to spend more time at work, and to opt for more work-related travel assignments. The mother became increasingly depressed, could not, on her own, summon up the energy required to maintain the son’s educational and health status, and lost her capacity to resist his demands for food. As a consequence, the son’s weight continued to increase; he stopped attending school again; he was rarely leaving his bed; and a medical assessment concluded that without a return to the previous routine, the son’s hypertension would become uncontrollable, and he would develop further, potentially life-threatening complications of both obesity and immobility. Though neither the mother nor father was capable of providing proper care for their son, they were also both adamant that the child’s care was their business alone and that health professionals and others should stay away. The health professionals noted that without adequate care, the boy would likely either die very prematurely or end up creating an indeterminate (and presumably vast) stream of medical costs that would come out of the public treasury and decrease the funds available to care for other patients.

In a standard textbook on health care ethics, the case would likely here with the question “What should be done?”—or perhaps with a series of questions about, for example, the various stakeholders, their rights and interests, which have priority, how one decides such matters, whether a 14-year-old is potentially competent to make decisions in his own behalf, and whether family privacy overrides the public interest.

What is certain is that such a case would provide the basis for a class discussion that would be interesting, engaging, or even exuberant. But engaging students in a classroom discussion is one thing. Reaching a single, sound clinical decision in a situation permeated with suffering and distress is quite another.

• Multistep Processes for Achieving Closure

For the purpose of reaching decisions in difficult clinical situations, bioethicists have proposed various sorts of multistep processes for health professionals to follow, enabling them to address all the relevant issues. For example, in Ethics and Law for the Health Professions ( 2013 , pp. 138–139), Ian Kerridge and colleagues present a seven-step process: (1) identify the ethical problem; (2) get the facts; (3) consider core ethical principles; (4) consider how the problem would look from another perspective or using another theory; (5) identify ethical conflicts; (6) consider the law; and (7) identify a way forward. The full scope of what is required becomes manifest only in the complete description of the seven steps (see Text Box 5.1 ).

Text Box 5.1: A Model for Ethical Problem Solving in Clinical Medicine

Identify the ethical problem:

Consider the problem within its context and attempt to distinguish between ethical problems and other medical, social, cultural, linguistic and legal issues.

Explore the meaning of value-laden terms, e.g. futility, quality of life.

Get the facts:

Find out as much as you can about the problem through history, examination and relevant investigations.

Take the time to listen to the patient’s narrative and understand their personal and cultural biography.

Identify whether there are necessary facts that you do not have? If so, search for them.

Use the principles of Evidence-Based Medicine (EBM) where possible when assessing or epidemiological evidence.

Consider core ethical principles:

Autonomy: what is the patient’s (or surrogate’s) preferences, goals and values; what is the patient’s approach to the problem?

Beneficence: what benefits can be obtained for the patient?

Non-maleficence: what are the risks and how can they be minimized or avoided?

Justice: how are the interests of different parties to be balanced? How can equity or fairness be maximized?

Confidentiality/privacy: what information is private and does confidentiality need to be limited or breached?

Veracity: has the patient and their family been honestly informed and is there any reason why the patient cannot know the truth?

Consider how the problem would look from another perspective or using another theory:

Who are the relevant stakeholders? What is their interest? What do they have to lose? How salient are their interests? How powerful are they? How legitimate are they? How urgent are they?

How would the problem look like from an alternative ethical position? For example, consequentialist, rights-based, virtue-based, feminist, communitarian, or care-based.

Has someone else solved a similar problem in the past? How did they do it?

Identify ethical conflicts (e.g. between principles, values or perspectives):

Explain why the conflicts occur and how they may be resolved.

Consider the law:

Identify relevant legal concepts and laws and how they might guide management.

Examine relationship between clinical-ethical decision and the law.

Identify a way forward:

Identify ethically viable options;

Identify the option chose, for example, by specifying how guiding principles were balanced or by clarifying what issues or processes were considered most significant, and why;

Be clear about who was responsible for the decision;

Communicate the choice and assist relevant stakeholders determine an action plan;

Document the process;

Assist/mediate resolution of any conflict;

Evaluate the outcome.

From Kerridge I., Lowe M., and Stewart C., Ethics and Law for the Health Professions , 4th ed. (Sydney: Federation Press, 2013 ). Reprinted with permission.

More concretely, in presenting multistep processes as a means of addressing ethical “dilemmas”—presumably, situations in which a straightforward application of ethical principles yields no unequivocal answer—bioethicists implicitly assert that such processes actually will lead, in some way, to the desired closure. But such processes, if brought to closure via a full consideration of all the relevant issues, are even more complex than Kerridge’s seven steps would suggest. Just how complex can be seen if we look not at bioethics but at what’s involved when law courts consider cases that have been appealed. In such situations, a lower court would have made a decision based on its consideration of both the law and the facts, as in a jury trial. On appeal—in a process that closely parallels the multistep consideration of difficult ethical questions in bioethics—the appeals court considers only matters of law, against the background facts as determined by the lower court. That process of appealing a decision by a lower court can be considered, for our purposes, as an elaborated version of Kerridge’s multistep process for addressing ethical issues in health care.

In considering the work of appeals courts, our goals are twofold: first, to understand the complexity of such multistep processes, and second, to understand why, in law, they actually work as a means of reaching decisions. In the section after that, we return to consider the use of multistep processes in bioethics.

• The Multistep Process of Appeals Courts

Framing and the Diversity of Perspectives

The work of appeals courts is to make decisions about the law in relation to cases that have previously been decided by lower courts. In particular, a case comes to an appeals court when one side of a case argues that the lower court, in making its decision, was mistaken in how it interpreted or applied the law. The task of the appeals court is to determine whether that interpretation or application was mistaken or not, given the facts as determined by the lower court.

For an appeals court judge (we will be taking U.S. appeals courts as a model here), 1 an initial step is to request each side to prepare a written legal brief presenting arguments to support their own interpretation of the law (or laws) in question—which is parallel to what happens in bioethics courses as students set out to defend their own views against those of their classmates. In these briefs, each side constructs, as it were, a view of the world that seeks to persuade the court to see the case in that way, too. For this purpose, the attorneys involved may well end up invoking the full range of factors used in ethicists’ multistep processes. Historical, cultural, and social factors might be part of framing—and arguing—a case. Linguistic factors are always important in law and may prove central, even decisive. No argument can be made without direct reference to established legal rules and to what that particular court and other courts have done in the past (i.e., relevant precedents ). Policies underlying a particular area of law are regularly invoked. And references to ethical principles are made, too, if they help to support one’s argument (e.g., by referring to factors such as “fundamental fairness”). Another crucial factor in preparing any legal brief, as in a bioethicist’s multistep process, is the need to anticipate and address the arguments of the other side; one test of this comes with oral argument, which enables the judge to probe the positions of the attorneys for each side.

In the case of our morbidly obese, bedbound teenage boy, let’s suppose that (1) a child-protection agency had attempted to remove the boy from his family, (2) the family, possibly with the assistance of some sort of pro bono or public organization (and therefore free or low cost), decided to oppose the removal, and (3) in a court proceeding, it was decided that the agency was legally justified in removing the child. If that decision was then appealed, both sides would be asked to prepare legal briefs presenting their positions. And if one assumes that the situation received attention in the local papers, one would also expect that there might be some, or even many, additional briefs submitted by amici curiae—friends of the court. A family-oriented, pro-parent group might insist that the rights of the parents be protected and that they be allowed to retain their child at home, no matter what the consequences. Likewise for any group writing from either the far right or far left, who would presumably be opposed to the intrusion of the state into what they considered a fundamentally private matter. Some groups representing health professionals or institutions would support the child-protection agency, arguing that protecting the health and well-being of the child is the community’s fundamental concern, whereas other groups might oppose removal, either to protect the psychological health of a disabled, dependent child or to prevent the child’s exposure to physical or sexual abuse in various sorts of foster-care settings. Law professors might write carefully researched, persuasive briefs on both sides of the dispute, often by citing not just the law but the sociological, historical, or anthropological factors relevant to the case.

It is difficult to overstate the potential degree of complexity in such situations. Each brief submitted not only argues in favor of a certain result but provides a distinct set of arguments that typically frame the case in a way that reflects the broader interests of whoever prepared or commissioned that particular brief. Based on such framing, the central issue in the case might be seen as one involving, among others, statutory interpretation, parental rights, children’s rights, state interests, abuse of power, domains of interest (public versus private), or the limits of the judicial authority. And each of these arguments might actually have some real merit.

The Complexities of Closure

In many legal cases, one might think that the availability of an established (and relevant) legal rule would carry the day and move directly to closure. If the case were so simple, however, it would never have been appealed (or accepted for appeal). For example, even when a judge agrees that, other things equal , “the established rule in such situations is that . . . ,” it is still an open question whether other things actually are equal. Deciding that question—and how narrowly or broadly to apply or interpret an established rule—is often a key element in the case, and a key element for judges to determine. In this context, courts need to consider all of the elements discussed in the preceding subsection and also a potentially wide range of subsidiary factors, including the following: How quickly is a decision required? Does the court have the time and resources to assess particular factors? Is there a simpler way of deciding a case without getting into complicated, controversial, or time-consuming issues? Is the issue “ripe”; that is, is enough known, often through previous litigation, about the factors relevant to a particular type of legal situation, enabling the court to make a reasoned, informed decision that is likely not to seem, in time, ill-founded or premature? Likewise, will deciding a case in a particular way end up upsetting established law, with the consequence that the decision would be considered unjustified or would create uncertainty in an area of law (e.g., contracts) where clarity and predictability are especially valued?

Against this background of conflicting legal arguments and, one might say, conflicting views of the world, the judge has to decide not only on a result—that is, which side “wins”—but also on the reasoning that led to that result and on what particular remedy, or course of action, to order. In the example we’re considering—the morbidly obese 14-year-old—the judge might decide in favor of the child-protection agency, set forth (or not) a set of reasons why the arguments presented by the opposing briefs were ultimately not persuasive, and then authorize the agency to remove the child but only pursuant to certain conditions. Such conditions might include (1) the availability of a public institution or even another family to take proper care of the child, (2) provision (or not) for the family to visit the child, and (3) conditions, if any, under which the child’s parents might petition the court to have the child returned home. Alternatively, and as often happens, the judge might decide in favor of the parents, provide a justification for that decision, and leave it to the child-protection agency to determine how best to protect the child at home.

What should be clear, no matter what, is that choosing exactly which arguments are “correct” (or stronger or more persuasive than the others) is no simple, determinate process. And it’s not as if there are only two potential results. A judge might find some middle or different ground for a decision—one not presented by any of the parties or amici curiae. The judge needs to take all the diverse factors into account, as best as he or she can, and with the knowledge that except in unusual cases, there will no single, correct answer, and no single correct legal analysis. Different judges and different courts may reach different results, and even when the actual outcome is the same, they may have reached that position through a different line of reasoning. Judicial decisions are as different as the judges themselves, each with their own sensitivities, political views, attitudes toward risk, need for control, and personal and intellectual histories, among many other differences.

What Makes a Judicial Decision a “Good” One?

That said, what makes a judicial decision a good one, and not merely a legally authoritative one because issued by a judge? The main criterion here is the judge’s capacity to credibly apply existing law and potentially to advance it (if only by a smidgen) while holding true to the constraints within which all judges are expected to act. These constraints include the facts as known, the diverse dimensions of existing law—statutory law (made by the legislative branch of government), case law (judicial branch), and regulatory law (executive branch)—and the wide-ranging histories, social forces, and public policies that have shaped these separate areas of law.

The broader institutional character of law comes into play here. Informed assessments of judicial decisions emerge, over time, though the work of other judges, lawyers, and potentially also commentators and critics from the academic community—which can be understood, in effect, as expressing the collective wisdom of the profession. This institutional feedback will influence, in the short term, whether the decision is appealed to (and changed or overruled by) a higher court and, in the long term, the actual “meaning” of the decision. A decision deemed good will generally be interpreted more broadly and therefore have more legal impact in both the short and long term than a decision deemed poor.

Over time, the overall impact of these assessments is to define relatively stable, fixed points in the legal system that enable lawyers and judges to determine what can and cannot be argued effectively, what can or cannot be reasonably interpreted as a point in contention. Likewise, by virtue of their legal training and professional experience, lawyers and judges come to understand which points are relatively fixed and which not, as well as how hard, and by what sorts of arguments, such fixed points can be questioned. Some points of law and some policies are more fixed than others; some points can be budged fairly easily (albeit only with very good reasons for doing so), whereas others require something much more than that. In the United States, for example, the confidentiality of the psychiatrist-patient relationship can be overridden only when the safety of another person is at risk—as in the case of a patient who tells his therapist that he is planning to murder someone. 2 Various constitutional doctrines have a similar, high threshold for arguing exceptions. Judge-made law actually does evolve, and sometimes change radically, over time. But in general, judges or lawyers who ignore or move too far away from established fixed points of the law are apt to find their own work ignored, disregarded, or disparaged.

Why Does the Judicial Process “Work”?

The persons implementing the model—judges and lawyers—are themselves experts in the relevant field : law. And they bring this expertise to bear throughout the process, from (at the very outset) deciding which cases to litigate, to every stage of the litigation, to the ultimate decision by, and reasoning of, the judge.

The law itself —substantively and procedurally—operates as a constraint. Substantive legal rules permeate and shape the process of judicial decision making, from outset to conclusion. These rules, though not inflexible, are relatively fixed signposts for such decision making. Procedural rules, such as those concerning documentary evidence or the examination of witnesses—keep the legal proceedings moving ahead on a defined path, and without having to recreate the process at every step and for every case.

More concretely, the history of each case serves to frame the relevant issues, and this history helps to determine, in effect, what points of fact and law are in contention, and which are not. It is not that the case, if it arose afresh, might not be seen as raising different issues. The point, instead, is that the history of a case serves to limit the range of issues and focus the attention of the court and the parties involved in the case.

The institutional framework of the law operates as a strong constraint on lawyers and judges, and serves to channel their attention and legal work. Beginning with the professional socialization that occurs in law school and continuing with the bar examination, professional organizations, continuing legal (and even judicial) education, and myriad other activities, life in the law is lived within educational, social, and legal institutions that define what it is to live and work as a lawyer.

• Revisiting Bioethics

The judicial process, as described above, can be understood for our purposes as a formalized, detailed version of the multistep process that Kerridge and colleagues ( 2013 ) recommend for addressing ethical issues in health care. As with the judicial process, the multistep process of ethical decision making should not be expected to produce unique, determinate, “correct” answers. It may be that, in the end, the various dimensions of the ethical problem at hand will be well, even deeply understood. But just how to integrate and balance the various factors remains indeterminate. As in the case of judges and the judicial process, different people will reach different results and for different reasons. More importantly, however, the multistep process in bioethics is not subject to the same constraints that channel the judicial process and that lead to what legal commentators see as generally good results.

The proposed multistep process for making ethical decisions incorporates none of the four constraints that channel the judicial process and that lead toward good, generally respected decisions. The most obvious and important difference is that health professionals are not experts in bioethics or in reasoning from ethical principles—the form of reasoning required by Kerridge and colleagues’ multistep process (or, indeed, by other multistep processes). Although bioethicists and philosophers undoubtedly feel comfortable with, and are adept at, analyzing ethical problems through the use of abstract ethical principles, they have reached that point only through explicit, lengthy training in academic programs designed just for that purpose. Needless to say, health professionals have not had that sort of training, and there is no reason to expect them to think and act as though they had.

A second shortcoming of bioethics’ multistep process is that ethical principles do not have the same, relatively stable and knowable structure as the law. As noted above, the judicial process operates within substantive and procedural constraints that channel the work of lawyers and judges—and it is just this rule-defined structure that law students learn in law school and that is, in large part, tested for in state bar examinations (without which no one can legally practice law). Put quite simply, these substantive and procedural constraints—the fixed points that serve to define an entire field of human activity—have no parallel in bioethics or in ethics generally. The problem here is easy to explain. Suppose that two ethical principles conflict. How does one proceed to address the conflict? Bioethicists and philosophers might have some relevant expertise. Health professional simply do not.

A third shortcoming of bioethics’ multistep process is that clinical situations raising ethical problems are not well defined in the way that they are in judicial decision making. Cases are not accepted for appeal because they have been, in some generic way, improperly decided by a lower court. Appeals are made, and accepted by higher courts, because some particular point or points of law—the grounds for appeal —may have been decided incorrectly by a lower court. This focus enables the process to move toward closure. By contrast, the bioethical process actually moves in the direction of increased complexity. The closer one looks, and the more exhaustively one attempts to address the full range of issues presented by an ethical situation, the more there is to see (with more and more issues to be explored and decided), the more complex the emotions experienced by the participants, and the more one moves away from a single, potentially determinate result. Judges expect such complexity and, indeed, are expected to make decisions that take into account such complexity. That’s their job! But it isn’t what health professionals are trained to do, and there’s no reason to think that they can do it, especially within the time constraints of clinical health care.

A fourth shortcoming of bioethics’ multistep process is that the institutional framework that constrains and channels the work of health professionals is oriented toward the provision of health care—understanding and treating disease and health-related problems. Analyzing difficult ethical problems by using abstract ethical principles is not part of that institutional framework. Health professionals are not trained, and not socialized, to deal with difficult ethical problems in that way. Health professional do, indeed, deal with such problems whenever they arise. But they do so only after careful discussions, insofar as possible, with colleagues as well as with patients and their families and carers. Each clinician brings to these discussions his or her own clinical experience and established, clinically informed ethical views. But using abstract ethical principles to address ethical problems is not an integral part of this process, and of what it is to live and work as a health professional.

• The Way Forward

Confronted with the suggestion that they engage in a multistep process for making ethical decisions, one can easily imagine the following—but hypothetical—response by health professionals:

Lawyers are trained in the complexities of such models, and they work with such models, in such systems, their entire professional lives. Likewise, judges learn to make decisions in situations involving innumerable complexities of law, ethics, and public policy, all with underlying human dimensions. Much the same might be said of bioethicists, who are specifically trained to deal with ethical principles and all their complexities. But we have not been trained in any of those ways, and we aren’t comfortable dealing with ethical theory and matters of public policy. Our world is concrete and clinical, and our goals are tied in with the welfare of our particular patients. In lieu of a multistep process requiring abstract analysis and the application of ethical principles, give us something that we can work with.

That’s exactly what the rest of the book is about.

Although we are, for the sake of simplicity, discussing the appeals process as if a single judge were deciding the case, federal appellate cases are typically decided by a panel of three judges. One judge writes the majority opinion, and the other two either join that opinion or write separate opinions of their own, either in concurrence or dissent.

By contrast, if the patient tells the psychiatrist about someone whom the patient has already murdered, confidentiality remains intact (Tarasoff v. Regents of the University of California, 1976 ).

• Kerridge, I., Lowe, M., & Stewart, C. (2013). Ethics and law for the health professions (4th ed.). Annandale, NSW: Federation Press.
• Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976).

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• Cite this Page Scher S, Kozlowska K. Rethinking Health Care Ethics [Internet]. Singapore: Palgrave Pivot; 2018. Chapter 5, The Elusiveness of Closure. 2018 Aug 3. doi: 10.1007/978-981-13-0830-7_5
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1 A Model for Ethical Problem Solving

• Published: April 2017
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Chapter 1 begins with a five-step model for analyzing a case posing ethical questions in pharmacy: (1) responding to a “sense” or feeling that something is wrong, (2) gathering information and making an assessment, (3) identifying the ethical problem, (4) seeking a resolution, and (5) working with others to choose a course of action. This five-step model is illustrated by the book’s first case, one involving reporting a possibly lethal medical error. A patient dies after mistakenly being given heparin intended for another patient. The case is followed by commentary applying the model and concluding with possible resolutions of the dilemma. The pharmacist might share the information with all those involved, including the family of the now-deceased patient, or tell only the pharmacist who prepared the drugs. The implications of the ethical principles involved, such as nonmaleficence and veracity, are explored.

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Examination of Ethical Decision-Making Models Across Disciplines: Common Elements and Application to the Field of Behavior Analysis

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• Published: 29 November 2022
• Volume 16 , pages 657–671, ( 2023 )

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• Victoria D. Suarez   ORCID: orcid.org/0000-0002-4940-0780 1 ,
• Videsha Marya   ORCID: orcid.org/0000-0002-5836-5470 1 , 2 ,
• Mary Jane Weiss   ORCID: orcid.org/0000-0002-2836-3861 1 &
• David Cox   ORCID: orcid.org/0000-0003-4376-2104 1 , 3  

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Human service practitioners from varying fields make ethical decisions daily. At some point during their careers, many behavior analysts may face ethical decisions outside the range of their previous education, training, and professional experiences. To help practitioners make better decisions, researchers have published ethical decision-making models; however, it is unknown the extent to which published models recommend similar behaviors. Thus, we systematically reviewed and analyzed ethical decision-making models from published peer-reviewed articles in behavior analysis and related allied health professions. We identified 55 ethical decision-making models across 60 peer-reviewed articles, seven primary professions (e.g., medicine, psychology), and 22 subfields (e.g., dentistry, family medicine). Through consensus-based analysis, we identified nine behaviors commonly recommended across the set of reviewed ethical decision-making models with almost all ( n = 52) models arranging the recommended behaviors sequentially and less than half ( n = 23) including a problem-solving approach. All nine ethical decision-making steps clustered around the ethical decision-making steps in the Ethics Code for Behavior Analysts published by the Behavior Analyst Certification Board ( 2020 ) suggesting broad professional consensus for the behaviors likely involved in ethical decision making.

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All articles with an asterisk indicate the final articles included in the review

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Suarez, V.D., Marya, V., Weiss, M.J. et al. Examination of Ethical Decision-Making Models Across Disciplines: Common Elements and Application to the Field of Behavior Analysis. Behav Analysis Practice 16 , 657–671 (2023). https://doi.org/10.1007/s40617-022-00753-1

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Frontline Initiative Code of Ethics

The right decision method: an approach for solving ethical dilemmas.

Annie Johnson Sirek, MSW is a Project Coordinator at the Institute on Community Integration at the University of Minnesota. She thanks Marianne and Julie of the Human Services Research Institute, and Amy and Derek of the University of Minnesota, for developing this method to use in daily practice and training.

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What is an ethical dilemma? 

An ethical dilemma requires a person to define right from wrong. But, as Direct Support Professionals (DSPs), we know that this is not so simple. We face difficult decisions in our daily practice. There are often many different rules, principles, and opinions at play. We are called to respond in allegiance to the individuals we support. The National Alliance for Direct Support Professionals (NADSP) Code of Ethics provides a roadmap to assist in resolving ethical dilemmas.

How do I resolve ethical dilemmas? 

Ethical dilemmas can be resolved through effective decision-making. Since we are so often called upon to make independent judgments, it is important to incorporate the NADSP Code of Ethics within our daily practice. Many ethical dilemmas can be resolved easily with consultation and reflection. However, some issues cannot. Therefore, to help make it easier to solve difficult ethical dilemmas, consider a framework from which to work. The College of Direct Support has provided an approach to ethical decision-making with the NADSP Code of Ethics. This is called the RIGHT Decision Method. 

RIGHT Decision Method 

• Recognize the ethical dilemma.
• Identify points of view.
• Gather resources and assistance.
• Have a plan.
• Take action based on ethical standards.

What is the RIGHT Decision Method? 

Sometimes there really is a “right” way to make decisions under difficult conditions. The RIGHT Decision Method gives us tools to make sound ethical decisions and resolve ethical dilemmas. RIGHT is an acronym that stands for each step of the decision-making process:

R: Recognize the ethical dilemma. 

The first step is recognizing the conflicting obligations and clearly stating the dilemma. It is important to recognize and use the NADSP Code of Ethics as you begin with this step. You may consider —

• In what ways is the Code of Ethics applicable to this issue?


I: Identify points of view. 

The second step is identifying points of view in the situation. This means considering the viewpoint of the person receiving services, your colleagues, other parties involved, and the NADSP Code of Ethics. Restating the problem clearly to someone else can also help you check out whether you have interpreted the situation accurately. It is important to understand how the person receiving supports feels. Consider —

• What does the person receiving support expect?

• Then think about others who are involved in the situation and how they feel.

• What do these individuals want or need?


G: Gather resources and assistance. 

The third step is gathering resources and assistance that might help you figure out what to do. Now that you have an accurate understanding for the problem and various perspectives, this step encourages you to consider other people who may be able to assist you. You may also need to find important information. For example —

• Are there agency policies that could be considered? What do these documents say? Are there any laws or regulations in the state that may influence your decision-making?

• Is this a situation where legal advice is needed? Does the person have a legal representative who must be involved?

• Are there community resources that might help resolve the problem?


H: Have a plan. 

The fourth step means that you are ready to make your decision. Formulating a plan will help you decide the best way to put your ideas into action. Once you have considered the following issues, write a plan down and identify step-by-step actions that you plan to take —

• Whom must you speak to first? What will you say? What preparations will you make?

• What steps can you take to ensure the best possible outcome for your decision?

• How might people react?


T: Take action based on ethical standards.  

The fifth and final step is implementing the plan you developed in the manner you decided. Then, it is important to monitor its success using the success indicators you identified in the planning process to help you reflect on your decision —

• What worked well and why?

• What did not work well and why?

• What would you do differently after you have evaluated your outcomes?

• Taylor, M., Silver, J., Hewitt, A., & Nord, D. (2006). Applying ethics in everyday work (Lesson 3) . In College of Direct Support course: Direct support professionalism (Revision 2) . DirectCourse.

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