Ethical Decision Making in Healthcare

Objective: Ethical decision making seeks to make judgments based on well-reasoned, defensible principles to avoid low-quality decisions and negative consequences.
Nature of Choices: * Right vs. Wrong: The simplest form of choice. * Right vs. Right: Situations containing "shades of gray" where alternatives have both desirable and undesirable results, often called choosing the "lesser of two evils."
Problem Definition: A "discrepancy between the current situation and a desired state" (Burkhardt & Nathaniel 2014).
Ethical vs. Common Problems: Ethical problems have no easy solution, involve value-laden terms (good, bad, harm, benefit), and are not reversible once a decision is made.

Moral Uncertainty: Sensing something is not right but being unable to define the specific problem.
Ethical Dilemma: A choice between two or more equally unfavorable options involving conflicts between moral principles, duties, rights, or values.
Moral Distress: Occurs when a professional knows the right action but institutional or external constraints make following that course nearly impossible.
Moral Outrage: Occurs when a nurse perceives an act by another health care setting member as immoral; the nurse is not directly involved and feels powerless to intervene.
Impact of Moral Distress: As noted by Eche, Phillips, Alcindor & Mazzola (2023), consequences include avoiding patient contact, strained capacity for caring, and leaving the nursing profession.

Uncertainty: Lack of predictability regarding action outcomes.
Context: The personal world of the patient which influences choice selection.
Stakeholders: Persons with strong or competing opinions involved in the decision.
Power Imbalance: Differences in influence due to real, perceived, social, or institutional power.
Extraneous Variables: Factors outside the care setting such as laws or previous legal cases.
Legal vs. Ethical Intersection: Acts may be ethical and legal, neither, or conflict (e.g., ethical but not legal). Clear legal answers preclude further analysis, while conflicts require deeper investigation.

Foundational Requirements: Resolving problems requires good will, collaboration, respect, confidentiality, and a patient-focused approach (Zoloth 2006).
Moral Justification: The act of providing good reasons for ethical decisions based on theories and principles.
Step-by-Step Reflective Model: 1. Define the Problem: State the nature of the issue and check for hidden conflicts or ethical dilemmas. 2. Assess the Situation: Collect factual and scientific data (medical diagnosis, legal info) and identify key persons' perceptions and cultural beliefs. 3. Consider Possible Courses of Action: List alternatives; evaluate legal, professional, and ethical consequences; and determine required resources. 4. Decide: Select the most acceptable action based on principles and conscience, and share justification with all parties. 5. Evaluate the Outcome: Reflect on the effectiveness of the action and use insights to revise future courses.

Role of Emotions: Callahan (2000) argues emotions provide information on right and wrong; practitioners should avoid "moral warning signs" like numbness or apathy.
Goal: To have "head and heart in harmony" when making decisions (Burkhadt & Nathaniel 2024).
Moral Reckoning (Nathaniel 2004, 2006): The process of coming to grips with the emotions of an ethical dilemma. * Stage of Ease: Initial comfort with values and professional norms until encountering a "situational bind." * Stage of Resolution: The nurse either stands up for moral convictions (e.g., whistleblowing, refusing orders) or gives up due to perceived futility or self-protection. * Stage of Reflection: Thinking about the event, reliving the story, and setting new boundaries for future actions.
Management Strategies: Purposely using ethics in the workplace, developing self-awareness, supporting distressed colleagues, and addressing imbalances related to ethnicity, gender, and race.