Ethical Decision Making
Just as nursing applies a systematic process for evaluating the condition of a given
population to determine an appropriate intervention, health care providers must also
utilize a systematic process to assess the nature of an ethical dilemma to determine a
Ethical decisions are reasoned choices based on:
The dilemma itself.
The principles in conflict.
The people involved.
The outcome of the proposed action.
The ethical reasoning process selected.
Ethical Decision Making
It is helpful to use a decision-making model for ethical dilemmas in order to guide one’s
decision making from an objective, cognitive perspective, rather than a purely affective
or emotional perspective. Uustal (1993) proposed the following steps to guide one’s
ethical decision making. Uustal’s model not only follows the nursing process, but also
includes values clarification when applying an ethical decision-making model.
Step 1: Identify the problem. Ask:
Who are people involved in the dilemma?
How are they related or interrelated?
What is involved in the situation?
After answering the above questions, identify the ethical dilemma and make a concise
statement of the problem. Then, state the conflict in values.
Step 2: State your values and ethical position related to the problem.
How does the issue fit with your personal values?
Are they congruent or incongruent?
Step 3: Take into consideration factors that relate to the situation and generate
alternatives for resolving the dilemma.
Step 4: Examine and categorize the alternatives. Identify those that are consistent and
inconsistent with your personal values.
If the most appropriate alternative is inconsistent with your personal values, another
provider may be needed to facilitate resolution. This eliminates bias and preserves your
own ethical integrity.
Step 5: Predict all possible outcomes for those acceptable alternatives.
Consider physical, psychological, social, and spiritual consequences, both short-term
What might happen if you follow Alternative A?
What might happen if you follow Alternative B?
Step 6: Prioritize acceptable alternatives. List them in order from the most acceptable to
the least acceptable.
Step 7: Develop a plan of action utilizing the list of acceptable alternatives. Determine
what you are going to do about this dilemma.
Step 8: Implement the plan.
Step 9: Evaluate the action taken. Ask yourself the following questions:
Did I do the right thing?
Were my actions ethical?
Characteristics of Ethical Dilemmas
Following is a review of the characteristics of ethical dilemmas:
The choice is between equally undesirable alternatives.
Real choice exists between possible courses of action.
The people involved in the dilemma place a significantly different value judgment on
possible actions or on the consequences of actions. That is why there is a conflict. If
everyone involved agreed, there would be no ethical dilemma.
Data alone will not help resolve the dilemma. One always wants more data, but it is
Answers to the ethical dilemma come from a variety of disciplines (e.g., psychology,
Actions taken in an ethical dilemma will result in unfavorable outcomes and/or
constitute a breach of one’s duty to another person. Although the action taken may
meet the needs of one person or party, it may result at the expense of another.
The choices made in an ethical dilemma have far-reaching effects on our perception
of human beings and definition of personhood, our relationships, and people in
society as a whole.
Any ethical decision involves the allocation and expenditure of resources which are
finite. If there were an infinite amount of resources to share with everyone in need,
there would be no dilemma in deciding who gets the scarce resource.
Ethical dilemmas are not solvable, but rather resolvable. A solution would mean that
the problem is fixed. A resolution means that a decision has been made to determine
a course of action in the situation.
When one is faced with an ethical dilemma, there are specific ethical questions to
What ought to be done in this case?
Who should be involved in the decision making process?
Who has the right to make the final decision? Why?
For whom should the decision be made: for oneself, someone for whom you are
acting as a proxy, or others?
What criteria should be used in a dilemma? Psychological condition only?
Physiological status, economic concerns, legal factors, social and family
perspectives, or spiritual considerations?
What degree of consent should be obtained from the client?
What harm or benefits will result from the decision and resulting actions?
Does the ability to intervene justify the intent to do so? Just because it is possible,
does it make it right?
As a response to the growing number of ethical questions stemming from scientific
advancement, President George Bush established a President’s Council on Bioethics in
January of 2002. A significant step to approaching ethical dilemmas was made when the
council mandated the creation of ethics committees in acute care settings. These
committees are comprised of members from different disciplines in and outside of health
care as well as laypersons from the community. Committees often include an ethicist
(educated in ethical consultation), a lawyer, a quality improvement manager, a
physician, a nurse, a clergyman or other spiritual director, and an individual from the
community at large.
In the coming together of differing experiences, educational backgrounds and unique
perspectives, the committee as a whole can produce a well-balanced discussion of
alternatives. In addition, these committees can provide recommendations intended to
advocate for patient’s rights and promote shared decision making, even in the face of
the most challenging of ethical dilemmas. While the alternatives and recommendations
offered by an ethics committee do not have the weight of law, they make a significant
influence on decision making at the bedside and have the power to influence a judge or
jury during any deliberation involving patient rights.
As long as the delivery of health care involves human life, changing technology, and
finite resources, health care professionals will face ethical dilemmas on a daily basis.
Often times, life-changing decisions must be made quickly. Because of the long-term
and life-altering effects of many actions, it is important that ethical dilemmas be resolved
in accordance with ethical principles and theories. Just as health care professionals
practice CPR in order to be able to perform it efficiently in a real situation, it is important
that health care professionals practice ethical decision making in a classroom setting so
that they are in tune with their own values and are better prepared to make ethical
decisions when they occur in the clinical setting.
Uustal. D. B. (1993). Clinical ethics & values: Issues and insights. East Greenwich, RI:
Educational Resources in Healthcare.