Scott Rae Moral Choices

Thursday 17 May 2012

MAKING ETHICAL DECISIONS

Chapter 4
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A model for making moral decisions

Rae suggests the following procedure for making moral decisions - within this his work is not to get you to the right answer but to help you ask the right questions in your ethical deliberation. Rae says his model is free from cultural, ethnic and religious background biases - though it is consistent with the bible and uses biblical principles, it is not a distinctively Christian model.
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A model for making moral decisions

It is oriented towards virtues and principles with consideration of consequences as a supporting role. Many moral dilemmas or issues are not addressed clearly, if at all, in the Bible. So we apply principles and virtues to each - the problem then becomes which to apply and how. Often weighting needs to be given to elements within a problem. There is a danger of trying to oversimplify things by claiming to be biblical.
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What is an ethical dilemma? (How would I know if I were facing one?)

An ethical dilemma is a conict between two or more value - or virtue driven interests.
You have to identify the parties in the conict, what their interests are, and what virtues and values underlie those interests. There follows Raes list of elements for making moral decisions:
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1. Gather the facts

The simplest way of clarifying an ethical dilemma is to make sure the facts are clear. Ask: Do you have all the facts that are necessary to make a good decision? What do we know? What do we need to know? In this light it might become clear that the dilemma is not ethical but about communication or strategy.
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2. Determine the ethical issues

Ethical interests are stated in terms of legitimate competing interests or goods. The competing interests are what creates the dilemma. Moral values and virtues must support the competing interests in order for an ethical dilemma to exist. If you cannot identify the underlying values/virtues then you do not have an ethical dilemma. Often people hold these positions strongly and with passion because of the value / virtue beneath them.
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3. Determine what virtues / principles have a bearing on the case

In an ethical dilemma certain values and principles are central to the competing positions. Identify these. Determine if some should be given more weight than others. Ask what the source for the principle is constitution, culture, natural law, religious tradition... These supplement biblical principles.
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4. List the alternatives

Creatively determine possible courses of action for your dilemma. Some will almost immediately be discarded but generally the more you list the greater potential for coming up with a really good one. It will also help you come up with a broader selection of ideas.
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5. Compare the alternatives with the virtues / principles

This step eliminates alternatives as they are weighed by the moral principles which have a bearing on the case. Potentially the issue will be resolved here as all alternatives except one are eliminated. Here you must satisfy all the relevant virtues and values - so at least some of the alternatives will be eliminated (even if you still have to go on to step 6). Often here you have to weight principles and virtues - make sure you have a good reason for each weighting
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6. Consider the consequences

If principles have not yielded a clear decision consider the consequences of your alternatives. Take the alternatives and work out the positive and negative consequences of each. Estimate how benecial each +ve and -ve consequence is some might have greater weight than others.
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7. Make a decision
Ethical decisions rarely have pain-free solutions - it might be you have to choose the solution with the least number of problems / painful consequences. Even when making a good decision you might still lose sleep over it!

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Applying the model: A case study

This has been adapted from Raes original. It is about medical ethics. - 67 year old Indian woman diagnosed with a form of cancer which is usually treated by chemotherapy. - at admission she is fully competent and able to make her own decisions - she knows something is wrong with her and appears fearful and anxious about what getting well might involve.
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- she lives with her son and his wife - the family appear happy - the son has taken responsibility for her as her husband has died - the son translates for her with almost all information needing translating - the son does not want her to know anything more than the bare minimum about the treatment as he fears she will give up on life and resign herself to dying - the son is strongly motivated by cultural and family values
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- The patient does not know her full diagnosis or the full eects of the chemotherapy - she knows she is sick and treatment will make her feel sick to her stomach as well as losing her hair You are the doctor - what would you do? Follow the familys wishes (based on their culture)? Decide the patient needs to know what is happening - tell her even if it increases her fear (and alienates you from the family)
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1. Gather the facts - go back over the information given and write down all the facts. 2. Determine ethical issues patient autonomy, including giving consent for treatment versus what a caring family think is best for the patient. In such a situation nurses are bound by what the doctor decides - yet still they have to solve the problem of obedience to the doctor with the patients integrity in being able to give informed consent.
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3. Determine what values / principles have a bearing on the case - the right of the patient to give informed consent chemotherapy is a very invasive treatment. This is recognised by law, the person has a right to control what happens to their body. Such dignity comes from being made in the image of God.

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- the obligation of the medical team to act in the patients best interest. They should do good for the patient whenever they can - to act with compassion (the family will also claim to be acting in compassion)

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- respect for the familys wishes and culture. Humility is the virtue which says the doctors must realise not all they think is best. How heavily do they respect family / cultural values? The family may think they are taking some of the burden for their mother by making the decisions and not telling her everything - this caring is highly valued by them - also the law regarding informed consent must be applied, and nursing stas obedience to doctors
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4. List the alternatives - attempt to convince the family of the seriousness of the treatment and why she needs to know - call an ethics committee conference to discus the case and try to convince the family to tell her These two options should be discussed prior to any further treatment. - override the familys wishes and tell the patient of her condition and the treatment
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- continue to follow the familys wishes, the son continues to translate and she knows nothing more - wait for the patient to ask questions about treatment and then encourage her to ask very direct questions of her family and doctor (another translator is required here) - bring in another translator and ask the woman if she wants to know the details of all that is happening - likely to cause cultural oense to the son
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5. Compare the alternatives with the virtues / principles - initially try to pursue all possibilities of talking with the family and the doctors trying to get them to disclose the information themselves - if above is unsuccessful you can either withhold or disclose information to the patient - use another translator and tell the patient (or ask if she wants to know full details of what is going on - this alternative respects her autonomy)
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- she can make it clear at this time she wants her son to make the decisions for her - this would satisfy most important principles / virtues - if she chooses to know then it is her who is challenging the culture, yet she retains her dignity and has full information - if nurses are unhappy with what is happening the most viable option is probably for them to be requested to be removed from the case
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6. Consider the consequences If you disclose the information directly possible consequences include; - family feel alienated, cultural values have been violated - family may take patient to another hospital - patient may give up - patient might be happy they are nally being told the truth
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If you continue withholding information possible consequences include; - patient continues to be fearful and anxious about the treatment - patient nds out somehow and trust is compromised - family are happy cultural values are being respected

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If you ask the patient if she wants to know through another translator, possible consequences include; - family are unhappy at disrespect for their cultural values - patient gets to speak for herself and make own decisions - she can choose to let her son continue making the decisions, both law and culture are satised here - patient will be relieved as she knows her wishes have been respected
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7. Make a decision - we have had to think through our ideas of respect for family and culture - how far should we go in respecting this cultural approach, is the patients best interest compromised, is her dignity as an individual respected? Rae suggests, Here it seems the alternative that involves asking the patient if she wants to know the details of her situation satises most of the virtues and values at stake and produces the best balance of consequences too.
Thursday 17 May 2012