HOW TO MAKE AN

ETHICAL DECISION

Ma. Cecilia C. Cuaresma, MD, FPAFP, MPH

Bioethics 3 – College of Medicine
Emilio Aguinaldo College
 It has been suggested that medicine is much
less accountable than other professions that
are responsible for the safety and well-being
of other people.

We are all under great pressure to prove

our worth and justify our continued
presence in the workplace. Healthcare
professionals should not be an
exception. The very nature of our job
demands that we come under open,
tough and fair scrutiny.
 THERE ARE NO EASY
ANSWERS IN MEDICINE,
MUCH MORE IN OUR PLACE
OF WORK WHERE LIVES OF
THE SICK ARE AT STAKE.

We need to be accountable
for our actions and the
decisions we make!
 Accountability applies to all facets of a
healthcare professional’s work, from the
practical skill-based procedures, through
the knowledge-based aspects, to the more
nebulous areas involving attitudes, ethical
considerations and judgments.

 What makes us good physicians and

what is the intellectual framework within
which we make decisions?
HIPPOCRATIC OATH
 The oath not to do harm to the patient

 To act always for his best interest

 To be totally in favor of life at all its

various stages
 SELF-AWARENESS

Life is much simpler for me as

a young physician.
But when I became a consultant and
academician, clinical decisions became
complex.
And as an administrator, decisions to be made
are complicated.
It is not easy when judgments are infused with
ethical considerations.
 Man In The Mirror

I’m starting with the man in the mirror

I’m asking him to change his ways
And no message could have been any clearer
If you wanna make the world a better place
Take a look at yourself and then make that
change
Michael Jackson
Ballard and Garrett
THE HEALTCARE PROVIDER
AS A PERSON:
 Much emphasis is placed on the kind of a
person one ought to be

 A healthcare professional must first of all

ought to be a virtuous person

 One who is habitually inclined to do the good

thing, no matter what the circumstances or
consequences might be
Rivera EF, Ethical Practice of the Profession, 30th UMED
Conference, 3 October 2008
 According to Aristotle, virtue is a particular
state of character that makes a man good, and
which makes him do his work well

 In order to fulfill the requirements of the ethical

codes, the person must have fundamental
virtues

Rivera EF, Ethical Practice of the Profession, 30th UMED

Conference, 3 October 2008
 A healthcare professional must have
morally-acquired virtues of:
 Compassion and Community
 Courage
 Forgiveness and Reconciliation
 Truthfulness
 Service and Stewardship
 Generosity and Thankfulness
 Justice
 Equality and Inclusiveness
 Peace
 SENSE OF PURPOSE
It is easy to lose one’s self in higher
positions without a higher sense
of purpose in life –
one that is bigger than self.
Sense of purpose must be grounded in
solid values.
Without it, power and position will soon
overwhelm the person.
 As I was reflecting on my position in a
prestigious hospital,
I was so afraid NOT of its heavy
responsibilities,
but of the power I have because of it.
I was so uncomfortable of the entitlements
brought about by the office, and the fear that I
would soon like it for no other purpose but for
personal recognition and applause.
It could be addicting and can get out of control.
 THE SEVEN DEADLY SINS

• Attitudes that underlie sins

• First identified by St. John Cassian
(360-435 A.D.) in his Conferences
• Refined by Pope St. Gregory the
Great (540-604 A.D.)
• A framework for self-knowledge
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

PRIDE HUMILITY

• Seeing ourselves as we are and not

comparing ourselves to others is
humility. Pride and vanity are
competitive
 THE SEVEN DEADLY SINS
Deadly Sin Opposing Virtue
GREED/ GENEROSITY
AVARICE
• This is about more than money.
Generosity means letting others get the
credit of praise. It is giving without having
expectations of the other person. Greed
wants to get its “fair share” or a bit more
• This can be a pitfall for many men of
positions in government
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

ENVY LOVE
• Love actively seeks the good of others for
their sake. Envy resents the good others
receive or even might receive. Envy is
almost indistinguishable from pride
sometimes
• The most difficult to do is to love the
unlovable. But it must be done.
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

ANGER/ KINDNESS
WRATH
• Kindness means taking the tender
approach with patience and compassion.
Anger is often our first reaction to the
problem of others. Impatience with the
faults of others is related to this
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

LUST SELF-CONTROL

• Self-control and self-mastery prevent pleasure

from killing the soul by suffocation. Legitimate
pleasures are controlled in the same way an
athletes muscles are for maximum efficiency
without damage. Lust is the self-destructive drive
for pleasure out of proportion to its worth. Sex,
power, or image can be used well, but they tend to
go out of control
• Know thyself in order to gain self-mastery.
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

GLUTTONY FAITH AND
TEMPERANCE
• Temperance accepts the natural limits of
pleasures and preserves natural balance.
This does not pertain only to food, but to
entertainment and other legitimate goods
• Anything in excess is bad. A sense of
proportion must prevail.
 THE SEVEN DEADLY SINS

Deadly Sin Opposing Virtue

SLOTH ZEAL
• Zeal is the energetic response of the heart
to God’s commands. The other sins work
together to deaden the spiritual senses so
we first become slow to respond to God
and then drift completely into the sleep of
complacency
• Our labor must be purposeful. God’s way is
our only way.
Of the seven deadly sins, choose one
of your biggest failing.
• Lust 35 %
• Anger 18 %
• Pride 12 %
• Sloth 10 %
• Envy 10 %
• Gluttony 9%
• Greed 6%
MTV News Special Report: “Seven Deadly Sins”
Poll Results, 1993
DANTE ALIGHIERI (1265-1321):
“The Divine Comedy”

• Perverted Love: Pride, Envy,

Wrath/Anger
• Insufficient Love: Sloth
• Excessive Love of Earthly Goods:
Greed/Avarice, Gluttony, Lust
 MOHANDAS K. GANDHI –
SEVEN SOCIAL SINS

• Politics without principles

• Wealth without work
• Pleasure without conscience
• Knowledge without character
• Commerce without morality
• Science without humanity
• Worship without sacrifice
 SELF-STUDY

SHARPENING THE SAW

FURTHER
 SIX APPROACHES TO
DECISION-MAKING
 Our own beliefs
 Science
 Common sense
 Laws
 Professional codes and guidelines
 Principles and theories of ethics
 WHY STUDY ETHICS?
 Personal beliefs vs. common sense 
personal beliefs (+/- coincide with others) vs.
common sense (generally accepted norms)
 Differences in common sense – search for
universal truths
 Science cannot address all issues
 Laws and standards – “Is that which is legal,
that which is right?
 What Are Standards?
Different Standards That Govern Our Lives:
• Etiquette – standards by which we judge manners to
be good or bad
• Legal – standards by which we judge legal right and
wrong
• Language – standards by which we judge what is
grammatically right or wrong
• Aesthetics – standards by which we judge good and
bad art
• Athletics – standards by which we judge how good
or bad a game is played
• Moral standards
 WHY STUDY ETHICS?
Three limitations of laws:
 Laws can be arbitrary (even if not
obviously so)
 Laws can be unjust (at least in some
situations)
 Laws may not expressly address the issue
at hand
 WHY STUDY ETHICS?
 Professional regulations, codes and
guidelines – suffers the same problem as
laws therefore can also be insufficient in
dealing with difficult decisions
 Principles and theories of ethics – provide us
with room to explore problem situations free
from the restraint of rules and sanctions
 Ethics permit (even thrive on) disagreement,
debate and conclusions that do not adhere to
norms, laws or rules
 WHY STUDY ETHICS?
 The disadvantage of ethics – do not provide
the answers, only more suggestions (ethicists
better at asking questions than providing
definite answers)

 Imperfections in problem-solving methods

allows us toleration of uncertainty
HOW CAN PHILOSOPHY HELP?
Help bring the following elements to decision
making in any context:
 Clarity: reasoned understanding of our own
position
 Plurality: consideration and understanding of
other positions
 Awareness: understanding criticisms of your
position and preparation of
counterarguments against them
 Flexibility: ability to adjust your position in
accordance to new events and information

 Justification: stated clear arguments in

support of your position and decision
 ENVIRONMENTAL
MILIEU & REQUIREMENTS
 VALUES IN PRACTICE
 Medicine involves uncertainties both as a scientific
endeavor and as a human endeavor
Hunter, a professor of literature with a strong involvement in medical
education, writes somewhat controversially, that clinical medicine
shares its methods of knowing with history, law, economics,
anthropology and other human sciences less certain and more
concerned with meaning than the physical sciences. But unlike those
disciplines, it does not explicitly recognize its interpretative
character or the rules it uses to negotiate meaning.
She is puzzled by the medical profession’s preoccupation with the gold
standard of science in clinical practice, and believes that medicine is
better characterized as a moral knowing, a narrative, interpretative,
practical reasoning.
 Biomedical model of care can be limiting and lead to
error or oversight
 VALUES IN PRACTICE
 Biomedical view or approach produces
narrowing of vision that, however
informative, can sometimes lead to error or
clashes with the values of others
 Openness is a requirement of respectful
interaction with others
 If doctors permit their own value judgment
to function without challenge, we risk
imposing them on others
 VALUES IN PRACTICE

 What we value shapes the way we see

the world and our own perspective
 Moral values are more than just
attitudes
 Moral values are the foundations for
judgments, decisions and actions
 MORAL STANDARDS
“Moral standards, then, are standards that deal
with matters that we think are of serious
consequence, that are based on good reasons
and not on authority, that over-ride self-
interest, that are based on impartial
considerations, and whose transgressions is
associated with feelings of guilt or shame
and with a special vocabulary. We absorb
these standards as children from a variety of
influences and revise them as we mature”
Velasquez, Elements of Moral Philosophy, 1997
 “The lines of morality are not like
ideal lines of mathematics. They are broad
and deep, as well as long. They admit
exceptions; they demand modifications.
These exceptions and modifications are
made, not by the process of logic, but by
the rules of prudence. Prudence is not only
first in rank of the virtues, political and
moral, but she is the director, the
regulator, the standard of them all.”

Edmund Burke
 MORALITY VERSUS ETHICS
• Standards of right and wrong
(morality)
• The study of our standards of right and
wrong (ethics)
• Ethics provide us the opportunity for reflection of
what is right and wrong
• If it is not “examined”, then it might not be
reasonable; able to reason because you can see
yourself doing it (the critical moment)
 REQUIREMENT OF REASON IN
ETHICS
• Moral decisions should be backed by good
reasons
• Moral decisions should be impartial
(exhortation for us to treat everything
equally; not arbitrarily)
Rachel, Elements of Moral Philosophy, 1997

• Feelings tell people many different things

• Morality consults reason, not self-interest nor
preferences
JUSTIFICATION & RATIONALIZATION
• Normally confused; not really the same
• Rationalize when you make a decision even before you
actually think or have weighed pros and cons; after
making it you then try and find a way to defend it
(“dig your heels”)
• Justification goes through the process of weighing
pros and cons; so when decision is done then have
benefit of reason; can defend a position
• Still has an openness to discourse after a decision is made
• People rationalizing will just say “BASTA”; can’t come out to
reason
 ETHICS AND FREEDOM
• Freedom is important because if human beings are
not free to make choices, then all we have will be
simply causality or determinism
Rachel, Elements of Moral Philosophy, 1997

• In determinism, action is already predetermined by

the stimulus
• Choices is to be able to distance oneself from the
stimulus and therefore can see the options
• Morality therefore sits on the leg of freedom
(freedom to make choices)
• Once freedom is gone, our culpability is diminished
 ETHICS AND FREEDOM
• The assumption of a moral life is the existence of
freedom
Rachel, Elements of Moral Philosophy, 1997

Sense of Good and Evil

• Absolute – more universal conception; achievement of full
potential (no agreement of “fullness”)
• Relative – something is good or bad in reference to a
particular goal (self-chosen)
• Evil is when we curtail what is fully human; coming from
immense power of human beings to curtail his potential; evil
comes from freedom (choice); evil is chosen
 MORAL PROGRESS
Political Maturity
• Moral discernment is guaranteed because of
political maturity
• Should be critical thinkers
• Moral progress needs politics (mature)
Intellectual Rigor
• When intellectual rigor is present, there is
political space for discourse
• We then could settle contentious issues not by
power but by reason
 MORAL PROGRESS

• Political space guarantees morality so that it

can thrive and progress

• Universal values are not enshrined somewhere

but something which needs discussion in the
political realm

• For moral outrage to occur, there should be a

political arena for it

• Create political space so that individuals can

argue with each other
CONCIENTIOUS MORAL AGENT
Someone who:
• Impartially considers everyone’s
interests
• Sifts facts/examines implications
• Checks soundness of principles of
conduct
• Revises earlier convictions
• Acts on principles
 INFLUENCE AND POWER MAPPING IN
A GOVERNMENT INSTITUTION
DEPARTMENT MEDIA
OF HEALTH &
OTHER Informal
GOVERNMENT Group 1 POLITICIANS
AGENCIES HR/ UNITS
UNDER MEDICAL/
DO ALLIED
Formal MEDICAL
Group Executive
Director Informal
Group 2
Nursing
Management Top Management
Formal Group 2
Informal
Group
Rank &
File BOARD OF Hospital Support
FORMER
TRUSTEES Services
EMPLOYEES
PUBLIC Rank & Formal
File Group 1
 SOME STAKEHOLDERS

• Partners – seek good management

• Advocacy Groups – seek human rights
• Political Leaders – seek public support,
political stability, public image, etc…
• The People – seek voice, and participation
in decision-making
ETHICAL PRINCIPLES
4 Key Ethical Principles

 Autonomy
 Beneficence
 Non-maleficence
 Justice
 Autonomy
 Respect a person’s right to make their own
decisions
 Teach people to be able to make their own
choices
 Support people in their individual choices
 Do not force or coerce people to do things
 ‘Informed Consent’ is an important outcome
of this principle
Beneficence (to do good)
 Our actions must aim to ‘benefit’ people – health,
welfare, comfort, well-being, improve a person’s
potential, improve quality of life
 ‘Benefit’ should be defined by the person
themselves. It’s not what we think that is
important.
 Act on behalf of ‘vulnerable’ people to protect
their rights
 Prevent harm
 Create a safe and supportive environment
 Help people in crises
Non – maleficence (to do no harm)
 do not to inflict harm on people
 do not cause pain or suffering
 do not incapacitate
 do not cause offence
 do not deprive people
 do not kill
Justice
 Treating people fairly
 Not favouring some individuals/groups over
others
 Acting in a non–discriminatory / non-prejudicial
way
 Respect for peoples rights
 Respect for the law
 ETHICAL PRINCIPLES
In Summary, when making a moral
decision, ask the following questions:
1. Does the action maximize social benefits and
minimize social injuries?
2. Is the action consistent with the moral rights
of those affected?
3. Will the action bring just distribution of
benefits and burdens?
4. What kind of person will one become if one
makes this decision?
5. Does the action exhibit care for the well-being
of those dependent on our decisions?
4 Ethical Rules
 Veracity – truth telling, informed consent, respect
for autonomy

 Privacy – a persons right to remain private, to not

disclose information

 Confidentiality – only sharing private information

on a ‘need to know basis’

 Fidelity – loyalty, maintaining the duty to care for

all no matter who they are or what they may have
done
 2 broad philosophical theories

 Consequentialism – taking the

consequences of our actions into
consideration

 Deontology – basing our actions on a set of

principles or duties
Consequentialism
 Actions are right or wrong according to the
balance of their good and bad consequences

 The right act is the one that produces the best

overall result

 Utilitarianism (what action has the greatest utility

- use/benefit/positive outcome) is a type of
consequentialism
Utilitarianism
 Most prominent consequence-based theory

 Based on the principle of utility

 Actions ought to produce the maximal

balance of positive value (e.g. happiness)
over disvalue (e.g. harm)
Deontology
 Duty or principle based theory
 An act is right if it conforms to an overriding
moral duty
For example – do not tell lies, do not kill.

 E.g. Christian ethics – The Ten Commandments

But Christian ethics are not important for some
people in the world so moral duties vary between
cultures and societies

 A moral duty or principle is one that is:

 laid down by god / supremely rational being
 or is in accordance with reason / rationality
 or would be agreed by all rational beings
Why Employ Ethical
Principles?
 Creating Harmony is Difficult
In The Healthcare Arena.
 Power
 Self esteem
 Communication
 Personality/Attitude
 Education Level
 Socioeconomic Class
 Culture (which constitutes the most
profound difference).
 Values
Changing HealthCare Environment
 Managed Care
 Increased Healthcare Costs
 Technology
 Baby Boomers
 Young and Old Life Spans
 Decrease in Healthy Lifestyles
 Lack of Healthcare Access/Insurance
 Feelings of Entitlements for
Healthcare at a minimal personal cost
How May Harmony Be Achieved?
 Through ethical principles/behaviors,
because they:
 Provide a unique opportunity for
personal fulfillment and self respect.
 Serve to make it possible for
professionals to deal with each other
on a human level with respect across
all disciplines.
Ethical Principles/Behaviors
Continued:
 Serve to make it possible for
professionals and clients to deal with
each other on a human level with respect
across all cultures and communities.
 Make it possible for strangers to achieve
understanding (if agreement is not
reached, toleration may be achieved).
 Ethical Principles/Behaviors
Continued:
 May make it possible for professional and clients
to agree on and respect each others rights.
 May make it possible for this agreement to carry
over into other aspects of life outside the
healthcare setting where the idea of Ethics may be
first introduced to the professional.
 May make it possible for provider and patient to
interact on the basis of shared goals.
Ethical Dilemma:
Deciding People’s Fate
 You are on a sinking ship and there is only
ONE lifeboat available.
 Posted on the side of the lifeboat is a sign
which reads, “Maximum Occupancy” - 8
persons…this boat will sink if over occupied.”

 Standing on the deck and waiting on board the

lifeboat are nine adults and one child.

 You must decide who dies. Be prepared to

defend your decision.
 Persons on deck
 You
 A young mother and her infant son
 A 75 year old retired physician
 His 68 year old wife
 A 17 year old, pregnant girl (this counts as
one person)
 A professional athlete (male)
 A member of the clergy
 A middle aged school teacher and
 Her husband, a banker
Who Boards the Lifeboat? Why?

 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
Who goes down with the ship? Why?

1.
2.
 Research Driven
Ethical Issues
With the advent and benefits of modern
research, moral conflict is inevitable
now and in the future.
 Stem Cell Research
 Research Cloning
 Genome Project Results
 Fertility Research
Ethical Questions for
Discussion

 Should children with serious birth

defects be kept alive?
 Should a woman on Medicaid be
allowed an abortion for any reason?
 Should organs for transplantation be
able to be purchased?
Ethical Questions for
Discussion
 Should people suffering from
a genetic disease, where future misery
is predicted, be allowed to have children?

 Should individuals be allowed to use

scarce healthcare resources when death
is inevitable?
 GUIDES TO MORAL
REASONING & ETHICAL
DECISION-MAKING
 MODEL FOR ETHICAL DECISIONS
1. Gather the Facts
• Frequently, ethical dilemmas can be resolved
simply by classifying the facts of the case in
question as the essential first step prior to any
ethical analysis and reflection on the case
• In analyzing a case, we want to know the
available facts at hand as well as those currently
not known but need to be ascertained
• Thus, one is asking not only “What do we
know?” but also “What do we need to know?” in
order to make an intelligent ethical decision.
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS
2. Determine the Ethical Issues
• The ethical issues are stated in terms of
competing interests or goods. It’s these
conflicting interests that actually make for an
ethical dilemma
• The issues should be presented in a ___ versus
___ format in order to reflect the interests that
are colliding in a particular ethical dilemma
• For example, in business ethics, there is often a
conflict between the right of a firm to make a fair
profit versus obligation to the community
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS
3. What Principles Have a Bearing on the Case?
• In an ethical dilemma, there are certain moral values or
principles that are central to the conflicting positions
being taken
• It is critical to identify these principles, and in some
cases, to determine whether some principles are to be
weighted more heavily than others
• Clearly, biblical principles will be weighted the most
heavily
• There may be also constitutional principles or principles
drawn from natural law that supplement the biblical
principles.
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS
4. List the Alternatives
• Part of creative thinking involved resolving an
ethical dilemma by coming up with various
alternative courses of action
• Although there will be some alternatives that you
will rule out without much thought, in general
the more alternatives that are listed the better the
chance that your list will include some high-
quality ones
• In addition, you may come up with some very
creative alternatives that you had not considered
before.
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS
5. Compare the Alternatives with the
Principles
• At this point, the task is one of eliminating alternatives
according to the moral principles that have a bearing
on the case
• In many instances, the case will be resolved at this
point, since the principles will eliminate all
alternatives except one. In fact, the purpose of this
comparison is to see if there is a clear decision that can
be made without further deliberation
• If a clear decision is not forthcoming, then the next
part in the model must be considered. At least, some
of the alternatives may be eliminated by this step of
comparison.
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS

6. Weigh the Consequences

• If the principles do not yield a clear decision,
then a consideration of the consequences of the
remaining available alternatives is in order
• Both positive and negative consequences are to
be considered
• They should be informally weighed, since some
positive consequences are more beneficial than
others and some negative consequences are more
detrimental than others
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 MODEL FOR ETHICAL DECISIONS

7. Make a Decision
• Deliberation cannot go on forever. At some
point, a decision must be made
• Realize that one common element in ethical
dilemmas is that there are no easy and painless
solutions to them
• Frequently, the decision that is made is one that
involves the least number of problems or
negative consequences, not one that is devoid of
them
Julius A. Lecciones, MD, Anatomy of Ethical Decision Making, Catholic Physicians'
Guild of the Philippines, 26 August 2011, Nasugbu, Batangas
 I SWEAR BY THE MUSIC

I swear by the music of the expanding universe and

by the eloquence of the good in all of us that I
will excite the sick and the well
by the severity of my kindness
to a wholeness of purpose.

I shall apply my knowledge, curiosity, ignorance

and ability to listen.
 I SWEAR BY THE MUSIC

I shall cooperate with wondering practitioners in

the arts and sciences, with all who care for
people’s bodies and souls,
so that the whole person in relationship shall be
kept in view, their aspirations and their unease.

The secrets of the universal mind

I shall try to unravel to yield beauty and truth.
 I SWEAR BY THE MUSIC

The fearful and sublime secrets

told to me in confidence
I shall keep safe in my heart.

I will not knowingly do harm to my patients,

I will smile at them,
and encourage them to attend to their dreams and
so hear the voices of their inner strangers.
 I SWEAR BY THE MUSIC

If I keep to this oath I shall hope for the respect

of my teachers, and of my patients and of the
community, and to be healed even as I am able
to heal.

David Hart
July 1987