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MAKING ETHICAL CHOICES An Ethical

Decision-Making Handbook for Health Care
Practitioners & ....

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MAKING ETHICAL CHOICES
An Ethical Decision-Making Handbook for
Health Care Practitioners & Administrators

Steve Abdool
Edgardo Pérez
Wilson Lit

Second Edition
MAKING ETHICAL CHOICES

An Ethical Decision-Making Handbook for

Health Care Practitioners & Administrators

Second Edition
Making Ethical Choices
An Ethical Decision-Making Handbook for Health Care
Practitioners & Administrators

Steve S. Abdool
Bioethicist & Director,
Regional Centre for Excellence in Ethics,
Homewood Health Centre
& Ethicist at the University of Toronto

Edgardo L. Pérez
CEO & President,
Homewood Corporation,
Professor of Psychiatry, University of Toronto

Wilson M. Lit
Chief of Medical Staff,
Homewood Health Centre,
Associate Professor, McMaster University

All Rights Reserved

Copyright © Steve Abdool, 2000

Second Edition, 2010

Cover art derived from Paul Gauguin’s Portrait of the Artist with the
Idol, c. 1893.

This handbook may not be reproduced in whole or part without

permission from the authors
We would like to thank our families as well as friends and colleagues
at the Homewood Health Centre for their support and encouragement.
Special thanks are also due to Jill Herne and Reid Finlayson for their input
and insights. Without them all, this handbook would not be possible.

Steve Abdool, Edgardo Pérez and Wilson Lit

Contents
Cases 1
Introduction 3
Considerations in Health Care 7
Ethics 8
Ethical Approaches 9
Defining Ethical Decisions 12
Ethical Dilemmas 14
Ethical Consensus 15
The Team 18
Effective Team Deliberation 19
Pitfalls to Avoid 22
Fallacies 24
Personal Values 27
Moral Reasoning 30
The Law 32
Professional Codes of Ethics 33
Institution’s Mission, Values, Policies & Practices 35
Ethical Principles & Guidelines 37
The Virtues 40
Ethical Decision-Making Model 42
Conclusion 53
Case Study 54
Endnotes 59
Bibliography 69
Appendix 1: Canadian Medical Association Code of Ethics 71
Appendix II: Canadian Nurses Association Code of Ethics 75
“Human beings owe each other help to distinguish the better
from the worse, and encouragement to choose the former
and avoid the latter. They should be for ever stimulating
each other to increased exercise of their feelings and
aims towards wise instead of foolish, elevating instead of
degrading, objects and contemplations”

John Stuart Mill, On Liberty

 Making Ethical Choices

Cases
A starving patient with anorexia who refuses nutrition or
hydration
Miss Jones is a 45 year-old single woman with a 12 year history of
severe anorexia nervosa. She was admitted because of ambivalence about
life and rapidly decreasing weight – 69 pounds, which is approaching a
dangerously low level given her height. Miss Jones is only ingesting
small amounts (sips) of water. She denies active suicidal ideation or
plan. She has had at least 7 admissions in the previous 5 years, and she
was force-fed on 1 occasion. All therapy has so far failed. Although she
sometimes feels that she would be better off dead, Miss Jones does not
believe that her life is being compromised by her refusal of hydration
and nutrition. She emphatically refuses to be force-fed, claiming that
it had previously been a very degrading experience and violated her
basic values and beliefs. There is disagreement amongst the team (which
includes 2 physicians) concerning how to care for Miss Jones in this
situation. Miss Jones’ closest relative, her father, feels that he is not in
a position to override his daughter’s wishes. What ought to be done?
Why?

A depressed man with newly discovered prostate cancer

Mr. James is a 67 year-old gentleman who has practically given
up on life since his wife and daughter recently passed away 6 months
previously in a car accident. Since this unfortunate incident, he sleeps
most of the time, barely eats, and lives a very reclusive lifestyle. He
admits to feeling suicidal at times, and he is currently being treated
in hospital for clinical depression. During routine examination and
assessment, it was discovered that Mr. James has prostate cancer with
possible metastases. The prognosis is poor. Should Mr. James be told
about his medical condition? Why?

An intimate relationship between 2 co-patients

Mrs. Smith is a 25 year-old married woman who was admitted
into hospital for the treatment of clinical depression. On admission,
she was accompanied by her husband and 3 young children. Her family
seems very supportive, and she wanted to include them in her recovery
process. 3 weeks later, the team discovers that Mrs. Smith is having an
intimate relationship with a male co-patient (whose diagnosis includes
personality disorder). The team is aware that this male patient recently

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Making Ethical Choices Making Ethical Choices

had an intimate relationship with another co-patient and he generally Introduction

practises unsafe sex. He was not prepared to divulge this information to
his new partner. What should the team do? Why? Health care practice and administration is fraught with complex
moral issues and dilemmas. Shifting paradigms in the health care system,
The pregnant patient suffering from schizophrenia such as limited resources, increased emphasis on patients’ rights, and
moral diversity, have profound and far-reaching ramifications that impact
Miss Grant is a 34 year-old single patient who was admitted for us all – health care recipients and their families, health care professionals
threatening behaviours toward her elderly mother. She has a 15 year and administrators, and other stakeholders.
history of paranoid schizophrenia, and she is often non-compliant with
her medication. Miss Grant generally lives on the street where she On the one hand, advances in medical technology have created
frequently abuses a variety of drugs and engages in unsafe sex. After 3 renewed hope and exciting horizons in our quest for cures and treatments
weeks of treatment in hospital, it was discovered that Miss Grant was 14 of illnesses that cause pain, suffering and, frequently, premature death.
weeks pregnant. She appeared shocked at this discovery. Her capacity On the other hand, the development of new investigative and treatment
fluctuated rapidly – she would insist on procuring an abortion one techniques have added complex and baffling ethical questions to old
moment, then deny, within minutes, that she was even pregnant. Miss moral quandaries in health care.
Grant’s mother was her substitute decision-maker. She wishes to have Generally, health care professionals and administrators
her daughter carry the foetus to full term. Once Miss Grant’s condition is conscientiously follow personal or interdisciplinary frameworks for
stabilized, she will inevitably return to the street and would most likely making decisions. These processes are enmeshed with a wealth of
continue to abuse drugs and practise unsafe sex. What should be done? professional and personal experiences. Yet, how often is the health
Why? care professional or administrator baffled by difficult and perplexing
circumstances that possess a value foundation. Commonly asked
A limb versus a life questions include: Which of these difficult alternatives should I choose?
What course of action is most appropriate in this situation, and who
Miss Gardner is a 74 year-old single woman who was admitted for
should so decide? Answers to questions such as these often have very
a femoral arterial graft. She experienced a cardiac arrest during surgery.
far-reaching ramifications, and they may on some occasions determine
Although Miss Gardner was successfully resuscitated, she needed to spend
whether a patient is treated fairly or, indeed, whether he lives or dies.
about a week in the Intensive Care Unit. Her medical history includes
mild cardio-vascular heart disease and a stroke ten years previously. Miss Arguably, current ethical decision-making models are inadequate
Gardner recovered from her stroke with only minimal physical deficits. and may even be perilously deceptive (by purporting to deliver sound
Following surgery, she developed a severe psuedomonas infection of her moral choices through over-simplified models or checklists) in claiming
graft, which formed an artificial aneurysm. Miss Gardner’s aneurysm to produce effective and morally justifiable decisions. This handbook is
could rupture at anytime and she would die. Alternatively, her surgical the result of an appraisal of major bioethical decision-making processes.
predicament could be resolved by having a high leg amputation. Miss These models include Brody’s Model,1 Bunting and Webb’s Model,2
Gardner emphatically refuses any further surgical intervention, stating Thompson and Thompson’s Model,3 Murphy and Murphy’s Model,4
that she has had enough and wishes to die. Miss Gardner appears to Aroskar’s Model,5,6 Curtin and Flaherty’s Model,7 Grundstein-Amado’s
possess competency to consent to, or refuse, treatment. What ought to Model,8 Laurence McCullough’s Model,9 Jonsen, Siegler and Winslade’s
be done? Why? Model,10 College of Nurses of Ontario’s Model,11 and Chidwick’s
Model.12
This decision-making model has been peer-reviewed and evaluated
for external validity in several health care institutions by administrators,
clinicians and patients. It proves to be invaluable to stakeholders in the
microcosms of institutional activity while, at the same time, contributing
to our efforts to enhance justice and benevolence in the macrocosm of
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Making Ethical Choices Making Ethical Choices

our general society. unnecessary pain and suffering, prolongation of institutionalization – a

Health care administrators and policy makers use the same logical waste of vital finite resources – and the indignity of a loss of freedom
process as clinicians in deriving ethical conclusions to moral quandaries and privileges. Health care providers and administrators may experience
that they face. The basic questions follow the same sequence, for a great deal of anger, frustration, and emotional distress that reflects in
example, “What is really at stake?” “Who are the stakeholders?” “How their private lives and health, as well as in their professional lives, and
does it impact this business?” “What are the external constraints?” and patients and their significant others suffer immense ramifications from
“Which of the various options most conform to the ethical principles reduced quality of care and treatment.
of justice and decency while retaining other legitimate interests (for Fourth, the microcosmic structure of the health care institution itself
example, duties to stakeholders such as the general public and insurance can be a potential source of difficulties, for example, conflict of interests
agencies)?” and loyalties. The way that the administrative structure is designed
The decision-making model offered in this handbook takes into usually creates a hierarchical system with individuals wielding varying
consideration the following realities: First, doctors are no longer sole degrees of power and authority. Indeed, such a structure might be quite
proprietors of health care delivery. Increasingly, patients are insisting necessary as it serves to ensure the smooth and efficient operation of the
upon their inclusion and active participation in decisions involving their institution. However, authority and power must be harnessed through
care and treatment. Patients are now dependent upon several disciplines ethical deliberation and conduct, and, arguably, the greater the thrust
of health care professionals for the provision of appropriate care and toward a democratic process, as a safety mechanism, the greater the
treatments. Additionally, front line health care professionals possess possibility for the achievement of just, fair, and non-discriminating
increased empowerment, each functioning within his/her legitimate decisions within the facility.
competencies. There is, therefore, a shifting paradigm in health care Finally, this ethical decision-making process takes into consideration
delivery from a paternalistic and autocratic modus operandi to a patient- the cultural diversity and moral plurality of our evolving society. From a
centred, multidisciplinary and, therefore, democratic approach. realistic and pragmatic perspective, it recognises that it is not uncommon
Second, while demanding greater individual accountability and to find individuals, professionals and lay people alike, whose moral
responsibility as health care professionals and administrators, there positions are the exclusive result of intuition, usually lacking in moral
is an increased expectation that hospitals and community health care profundity and discernment. Its process is respectful of, and sensitive
organizations will form partnerships. They will hopefully work together to, individuals’ autonomy – their feelings, thoughts, beliefs and moral
in making important decisions to provide efficient and effective convictions – even when these are sometimes obscure and amorphous.
treatments in an uninterrupted continuum of care to patients. These new This model considers the realism of moral plurality an advantage
alliances, some institution-based and others community-based, have and, with the welfare of the patient as the primary focus of attention,
their own cultures, norms and philosophies with years of practices in engages an appeal to the consciences and convictions of its members
relative isolation. Not surprisingly, then, collaborative decision-making through rational discourse and argumentation, to arrive at a choice that
poses an enormous challenge as the alliances attempt to develop common is most appropriate under the circumstances. As an eclectic and dynamic
frameworks and policies through shared values and priorities. process, it engages the collective, committed, and collaborative efforts of
Third, ethical knowledge and analytical skill remain sporadic and all legitimate stakeholders in yielding the right choice.
deficient in the training curricula of health care professionals as they are A most appealing aspect of this model is that it offers a philosophically
for health care administrators. There is a lack of a consistent, coherent sound and reflective process on pressing ethical problems in clinical
and comprehensive decision-making process in directing health care practice which would yield a sort of ‘street level’ deliverable philosophy.
professionals and administrators to rationally, systematically and effectively That is, it does not necessitate an in-depth understanding and knowledge
resolve ethical dilemmas. Consequently, patients – the primary purpose of philosophical theorising by all team members. This methodological
of having a health care system – experience inappropriate choices in care ethical decision-making process provides for fair decision-making
and treatment modalities. They can sometimes endure immeasurable and for patients, health care professionals, and administrators, such that

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6
Making Ethical Choices

of health care resources).

decisions are not arbitrary, malevolent, or ill-informed.

applies to access to adequate and reasonable care and to the distribution

accordance with their consciences), (iii) patient’s well-being and best
individual dignity and worth, (ii) professional and personal integrity
are (i) patient autonomy (or right to self determination) which respects
The cardinal values that this decision-making process espouses
everyone, including society at large, may be confident that institutional

interest (a primary goal for care intervention), and (iv) justice (as it
(which respects the right of decision makers to deliberate and act in

Considerations in Health Care

Always opt for the
Always strive to do cheapest treatment? Is society safe under
the very best for one’s these circumstances?
individual patients? Professionals’
duties and What is my priority?
Always opt for the best Codes of obligations to patient Patient’s
treatment? ethics values,
Duty to profession wishes and Maximize autonomy?
Law of the land preferences
Tell the truth?
Hospital Third Party
values, mission, considerations: What is my role?
& mandate Clinical info society
Who are the
stakeholders?
History info family
Hospital’s duties & Examination other patients Keep this confidential?
obligations Hypothesis testing insurance
Respect patient’s Diagnosis
wishes? Prognosis
Treat this patient rather
Resources than that one?
Use scarce resources for
Time constraints
the greatest benefit? Does the end justify
the means?
Making Ethical Choices

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Making Ethical Choices Making Ethical Choices

Ethics Ethical Approaches

Ethics or morality is the reflective and analytical study of morals. There are at least three different philosophical perspectives to
It is the branch of philosophy that critically considers what is “right” the resolution of moral dilemmas. First, there is the ‘theory-based’
or “wrong” and “good” or “evil” in all matters of human conduct. approach. Two of the commonest ethical theories in health care are
Anything that has a value component – rights and entitlements, duties utilitarianism and deontology.15
and obligations, meaning, justice and fairness – is ethical in nature. Utilitarianism takes the position that the morally right action
Ethics in the health care context is commonly known as Bioethics. focuses on consequences by promoting the greatest balance of happiness
Bioethics may be defined as the analytic activity in which the concepts, over pain. John Stuart Mill (1806-1873), a British philosopher and
assumptions, beliefs, attitudes, emotions, reasons, and arguments politician, was one of the most avid classical utilitarians, and discussions
underlying medico-moral decision-making are critically scrutinized. around utilitarianism hinge on his theory.16 While utilitarianism remains
Medico-moral decisions are perceived to be those that concern norms or an extremely compelling ethical theory, one of the most important
values, good or bad, right or wrong, and what ought to be done in clinical objections made against it is that it could permit the treating of rational
practice.13 beings as mere means, rather than as ends.
In health care, there frequently exist competing and conflicting Deontology, on the other hand, considers morality in terms of
values and interests in a context of limited resources, shifting clinician rules that have intrinsic moral value, irrespective of outcomes. Truth-
roles and responsibilities, innovative medical technology, as well as telling and promise-keeping are examples of typical moral requirements.
cultural, religious, and moral diversity. Examples of ethical issues in The deontological ethical theory that is primarily used in health care
health care include genetic manipulation, civil commitment, withholding is derived from a German philosopher, Immanuel Kant (1724-1804).
and withdrawing life-sustaining treatments, cloning, medical research, Kant’s deontology forbids us to treat human beings as mere instruments
abortion, euthanasia, informed consent, allocation of finite resources, to our ends without respecting the fact that they too have ends. We
enforced treatments, and a host of other pressing health related issues must treat each person with respect and dignity. Another very important
that impact us all. maxim of his philosophy holds that by making a certain ethical choice I
As a discerning process, then, Bioethics ensures a methodology of also give permission to everyone else to act likewise in morally similar
rigorous ethical analysis and sound argumentation in the identification, circumstances.17 For example, in order for it to be morally acceptable
resolution, and prevention of ethical dilemmas in clinical practice. for me (as a health care professional) to have an intimate relationship
Biomedical ethics distinguishes itself from law by enquiring deeper into with one of my patients, it should be acceptable for all health care
the essence of rational existence and moral conduct, and it distinguishes professionals to develop intimate relationships with their patients under
itself from religion and personal opinions by requesting rational similar situations.
justification rather than offering simple ‘rationale’, for example, an It is from such theories that major moral principles are derived,
appeal to authority.14 for instance, beneficence, non-maleficence, respect for autonomy,
and justice. (These principles will be described later on page 33.) It is
Ethics highly desirable to focus on the various ethical principles rather than
the ethical theories in attempting to resolve ethical dilemmas. Exploring
Anything involving values ethical theories at the discussion table could accentuate differences of
perspectives and side-track from the pragmatic issues. Having said this,
Rights - Duties - Obligations - it sometimes becomes necessary to examine the theories, the basis if you
Justice - Fairness - Meaning will, for the moral principles themselves. This is one of the reasons why
it is extremely important for at least one member of the team to possess
sound ethical knowledge and argumentation skills – increasingly, the
Bioethicist fulfils this role.

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Making Ethical Choices Making Ethical Choices

Second, the ‘casuistry approach’ typically utilizes particularities The Objects of Moral Evaluation
and circumstantial detail as well as maxims in order to arrive at ethical
decisions. It is noteworthy that Western judiciary systems are casuistic
in their methodology of case analysis. It also considers precedent-setting
cases.18
Third, the ‘consultative approach’ promotes open discussion and
dialogue among team members.19 To date, none of these approaches have Characteristics of the Act Itself:
offered a categorical and unequivocal moral perspective in analytically Can be universalized (Kant)
negotiating moral dilemmas. Does not violate rights (rights theories)
Each of these valid ethical approaches offers valuable and cogent Acts Conforms to God’s commandments?
arguments, and bears legitimate considerations in the ethical decision-
making process. This decision-making model takes the position that Consequences:
the multidisciplinary team approach, as a vital aspect of the ethical For the individual (ethical egoism)
decision-making process, is most conducive to the best morally For everyone (utilitarianism)
weighted and rationally considered choice in today’s clinical setting and
in the predictable future of the health care system. In such a diverse
Focus of Moral
environment, the ethical decision-making process must also be able to
Evaluation
appreciate and accommodate each valid ethical approach.
It is not the purpose of this handbook to undertake a detailed analysis
of ethical theories or principles, or of meta-ethics20 and descriptive
ethics.21 These require elaborate ontological and epistemological inquiry
Intentions:
and argumentation that are beyond the scope of this text. With respect to
Done for the sake of duty (Kant)
meta-ethics, it should be borne in mind that: (i) it is extremely difficult
Done because God wills it?
to attain meta-ethical consensus, and (ii) by reason of the pressing Agents
nature of medico-moral complexes, one is bound by time constraints
and cannot wait for meta-ethical deliberation and consensus. Suffice it Character:
to say that a sound knowledge of moral theories and principles (upon Promotes human flourishing
which they are based) as well as meta-ethics and descriptive ethics can (virtue ethics)
be an invaluable asset in the ethical decision-making process. While
not necessarily utilizing these in open team discussion – this might well
hinder the process and, indeed, intimidate non-philosophically orientated
individuals – they serve as a foundation for the clarification of elusive
concepts and terms.
Ethical analysis involves both the action and the agent. Consequences
and motivation are crucial considerations in moral evaluation.

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Making Ethical Choices Making Ethical Choices

Defining Ethical Decisions professionals and to specific lay persons, for example the patient (or his/
her alternative decision-maker if this is necessary) and his/her immediate
Ethical decisions are derived from three basic elements: first, they family, as well as potentially to ‘passive participants’ – citizens from
are the result of the rational and judicious analysis of all the pertinent the general public.23 The procedure should not be contingent upon all
considerations such that another group of rational individuals considering active participants possessing a certain degree of intellectual or medical
the same circumstances would most likely reach the chosen alternative. knowledge. Otherwise, some legitimate participants would be excluded
Second, they are such that most, if not all, of the affected individuals from the process, and others would feel daunted and burdened. Everyone
could live with them on their consciences. Third, ethical decisions should be able to easily understand, appreciate and respect the process
should adhere to universal moral principles, such as respect for persons through which the decision was made.
and autonomy, beneficence, non-maleficence, and justice, rather than
simply appeal to intuitions or personal opinions.
It would be folly to suggest that the team approach would somehow
ensure an ‘absolutely correct’ decision – if such a thing even exists.22
However, a methodological
decision-making process
attempts to offer a decision
An Ethical Choice
that is the most appropriate Adheres to moral principles
considering all relevant Most likely what other reasonable
factors and with the least people ould choose
influence from biases
and ignorance in a given What stakeholders could live with
time period for a specific on their consciences
society. Congruent with patient’s values,
As opposed to being beliefs and preferences
able to rationally justify a Does not degrade or dehumanize
particular moral position, anyone
having a ‘rationale’ simply
means that one is able to
offer a consistent set of
(personal) reasons for holding a certain position. The beholder would not
have necessarily considered and addressed the other options or legitimate
sources of morality. From this definition, then, the Ku Klux Klan could
readily provide a rationale for their ‘philosophy’, that is, a consistent
and elaborate set of reasons as derived from certain presuppositions
(premises that most reasonable persons might call biased and prejudicial
in nature).
A morally sound ethical decision-making process must take
into consideration the magnitude of the ramifications of its deliberation
through both the audience that is required for active reflection, as well
as the audience that it frequently attracts. In other words, it should be
readily accessible, intellectually, to ‘active participants’ – health care

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Making Ethical Choices Making Ethical Choices

Ethical Dilemmas Ethical Consensus

At the heart of ethical quandaries is a set of value choices about The phenomenon of ethical consensus in health care quandaries
which there are deep concerns, disagreements, ambiguity, and uncertainty. is exceedingly complex, and it is beyond the scope of this handbook
What actually constitutes ethical dilemmas is the fact that it is difficult to undertake an analysis of its complicated philosophical arguments.
to perceive clear or distinct resolutions, and when the general principles According to the Oxford Dictionary, there are two basic definitions of
upon which one would usually appeal offer no assistance or, indeed, appear ‘consensus’. One definition of ‘consensus’ is ‘unanimity’. Considering
to contradict one another.24,25 One is faced with at least two alternative the legitimate plurality of moral sources, and the argument that it
choices, usually the result of conflicting ethical principles and interests, would be morally reprehensible to expect a dissenter to go against
none of which appears to be a satisfactory solution to the problem.26 It his fundamental values and principles28, ‘unanimity’ is perceived as
is also likely that all of the alternatives being considered might appear being too restrictive, idealistic, and impractical an approach in moral
equally appealing. Furthermore, ethical dilemmas may be perceived as deliberation (especially in clinical practice and its morally and culturally
involving conflicts and tensions arising from interrelationships.27 diverse environment).29
The position that this handbook takes is concordant with the second
definition of ‘consensus’ which relates to the general or collective
agreement of opinion. It is the judgement arrived at by most, if not all,
legitimate members. This leaves room for dissenters to remain loyal to
the team while allowing the decision to progress (or to excuse themselves
if the disagreement is hopelessly irreconcilable while maintaining
confidentiality). This is not the same sentiment as a ‘democratic vote’ in
An Ethical Dilemma which the dissenters are not co-opted in loyalty to the decision.
In reaching consensus at the bedside, it is important that should
A perplexing situation with front line health care providers somehow influence the operational
ambiguities and uncertainties policies and procedures of the institution. This sentiment increases the
probability for consensus through mutual moral agreements in a shared
Difficult to prioritize competing/
corporate culture. An atmosphere that fosters disgruntled, fatalistic and
conflicting values/interests
insecure employees cannot be conducive to the effective resolution of
No clear (appealing) alternatives very sensitive issues nor to the success of the institution.
In this process, dissenters can perceive, appreciate, and applaud
At least two equally appealing the sincerity and thoughtfulness of the rest of the members of the team,
alternatives noting that the decision was attained with good conscience and utilizing
sound ethical principles. It is crucial to remember that what is important
is not compromise or consensus so much as reflective convergence
towards consensus, which is sufficiently open, forthright, and candid so
that dissenters can, at a minimum, appreciate its logic and wisdom, if not
go along with it.
This process of moral reasoning and its inherent propensity toward
general moral agreement and consensus also makes it easier for the
dissident to respectfully remain loyal to his/her team’s choice. He/she, as
an active participant in the procedure, should have, at a minimum, a respect
for the impartiality of the process and its noble aspirations. Otherwise,
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Making Ethical Choices Making Ethical Choices

he/she retires from the team while maintaining confidentiality. The adult of the discussion, and the generally common goal – the welfare of the
competent patient’s final decision carries the day, in the sense that should patient.
this be irreconcilable with the rest of the team’s choice of action, then It is important to remember that compared with true consensus,
the patient has the prerogative to veto any proposed course of action ‘ignorant consensus’ is usually relatively easy to achieve. Employees
and to consult another clinician/health care facility. The treatment team are either intimidated and coerced, if not compelled, to acquiesce to tacit
honours such a right to refuse treatment. Under special circumstances, inter and intra-disciplinary and intra-institutional agendas, expectations,
however, such a right may be restricted.30 and peculiarities, or they may do so sincerely believing that the position
Modern societies are culturally diverse. However, individuals and held by someone in authority (for example a discipline director or
groups share many things in common, for example, general lifestyle and administrator) must possess ‘validity’ (that is, a rationale). This might
a basic moral conviction. According to Kurt Bayertz (1994) “This may or be quite adequate for individuals ignorant of ethical deliberation – thus
may not lead to universal and comprehensive consensus, but it frequently committing the fallacy of appealing to pseudo-authority.
results in a network of “moral family resemblances” among individuals The ‘impartial facilitator’ (usually the Bioethicist) in the decision-
and groups: a “patchwork” of local dissent and consensus.”31 Consensus, making process would serve to ensure that all legitimate interests are
then, may not be as difficult to achieve as is often presented. Generally, duly considered, and fallacies are not committed (in part through rigorous
some relative agreements (and disagreements) exist, and consensus argumentation). Loyalty to one’s employer and institution is certainly a
might be enhanced by the employment of impartial moral reasoning, very important consideration and, indeed, obligation. However, such a
and by focusing on building through the threads of agreements, rather responsibility is not without qualification, and it is possible to argue that
than to attempt to resolve entrenched and unyielding disagreements, for the duty to rationally seek a morally correct decision for one’s patients
example, by emphasizing differences in legitimate moral sources. trumps this obligation.
The decision arrived at should then be a reflection of an active and
collective process. Bayertz wisely argues that “Consensus has a claim
to moral authority only when it is the result of a rational communicative
process aimed at intersubjective understanding and a just balancing
of interests.”32 Consensus is usually forthcoming through a process of
moral reasoning, and this is augmented in an atmosphere wherein team
members pay serious attention to one another’s moral position with
respect, tolerance, honesty and sensitivity.
Moral reasoning, then, is perceived as tending toward agreement
rather than disagreement amongst a group of morally sensitive and
rational individuals. Non-reflective (that is, intuitive) opinions are voiced,
and the individual is respectfully prompted to scrutinize these in order
to achieve greater insight
into the particular position Moral Consensus
held. It is possible to argue
General or collective agreement
that this rational discourse
of opinion by most if not all team
serves to accentuate
members
common moral threads
of agreement rather than NOT unanimity (too restrictive,
disagreement, by virtue of impractical and unrealistic)
the perceived impartiality of
the process, the rationality

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Making Ethical Choices Making Ethical Choices

The Team Effective Team Deliberation

The team consists of the patient, representation from his/her
33
Professional team support is critical, and multidisciplinary team
significant others34 and a representation from each health care discipline members are required to suspend decisions during the initial stages
that is directly responsible for the care of the patient, for example, the of the process. Everyone must work within the competency of his
attending doctor, the primary nurse, the social worker, occupational profession and capacity to engender a comfortable atmosphere of care
therapist, and physiotherapist. and commitment to the expeditious resolution of the perceived problem
Additionally, consultation from a psychiatrist, should there be any and a return to a state of equilibrium in the patient-team relationship.
questions pertaining to the mental status or competency of the patient, The distress that arises from the complex should not be trivialized or
should be available. In view of the deficiency in the training of health marginalized.
care professionals in ethical theory and analytical skills, it is highly Goal setting is extremely important for the team. Objectives,
desirable that at least one member of the team demonstrates reasonable specifically directed at the welfare of the patient (as perceived by himself/
proficiency in these areas. Arguably, the Bioethicist is best suited to herself, providing that he/she is a mentally competent adult) ought to
reconcile the conflicts of pertinent interests/principles and a plurality of be elucidated. Clarification of the objectives are important so that each
legitimate considerations. team/committee member can possess a firm grasp of the goals that he/
It is not uncommon to find that health care professionals experience she is striving toward, and to commit himself/herself to this task at hand.
‘moral distress’ as a result of the traditional autocratic decision-making This saves time, money, and confusion.
process or, indeed, from a sole decision-making approach. Jameton During the entire
(1984) describes ‘moral distress’ as a state of psychological distress collective process, the group Engender a comfortable atmosphere
experienced by the health care provider (most often the nurse) who should be well focused of are and commitment to the just,
makes a moral decision concerning the care of a patient in his/her on the subject matter – fair and expeditious resolution of
care, but is unable to implement this decision by reason of institutional sidetracking and defocusing the dilemma.
constraints.35 This often results in feelings of moral outrage, rejection, should be minimized. Time Team members should suspend
and disillusionment, which can have adverse effects on the health of constraints are often crucial decisions during initial stages of the
very dedicated and caring health care professionals and their ability to considerations in clinical process.
function optimally. Consequently, the quality of care and treatment to practice: first, because a
patients deteriorates and, indeed, the general efficiency of the institution critical decision must be
is reduced (for example, through staff sick leave/absenteeism, and reached very urgently; second, in times of shortages of finance, it would
prolongation of patient stay). be prudent to use work time responsibly; and third, defocusing and
sidetracking can convey the message that the matter at hand is trivial
and unimportant.
Team It is important to remember that most groups have their prima
Patient (or substitute decision donnas, a self-elected officiator who enjoys being the spokesperson, if
maker/significant other), attending not the leader.36 In the multidisciplinary team process for ethical decision-
doctor, nurse, social worker, OT, making, such a destructive activity must be avoided. With respect to the
other health care professionals and process of effective discourse, Bruce Ackerman (1989) argues that one
invited persons should exercise “conversational restraint.”37 It is highly desirable to avoid
discussions concerning “ultimate truths”38 and to direct the discourse
toward more pragmatic considerations – the pertinent, particular
aspects of the situation being discussed by the team. It is much wiser to
emphasize agreements rather than to quibble, sometimes endlessly, over

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irreconcilable disagreements. Such an approach creates a psychological everyone, especially the lay person, could appreciate and comprehend.
atmosphere that is much more conducive to arriving at common and Professional team support is crucial – mutual trust, support, and
shared social values that everyone could live with – to consensus. respect are vital. In particular, respect and sensitivity to one another’s
Furthermore, it is important for each person to feel personally moral positions form essential facets of the process.
involved and his/her input as being very valuable in the proceedings.
Members ought to feel satisfied with their input and not inadequate.
In determining the goals and tasks at hand, one should ensure that the
situation is approached very positively and enthusiastically, and the
discussion should be engaging, flexible/compromising, and creative.
These characteristics tend to foster an environment wherein mutual
Do not trivialize/marginalize what is
trust, support, and respect are cultivated by team members. This impetus
at stake.
toward sharing, along with respecting and understanding others, often
leads to a cohesion – a sense of unity in the team. Hostilities are kept to Goal/objective setting - reinforces
a minimum, because the conflict is being dealt with constructively and commitment, prevents confusion
respectfully. and saves time and resources.
It is common practice that a body of professionals often shares a Each team member acts according
set of linguistic terms and expressions that are usually peculiar to its to his/her professional competency.
members, and this is especially apparent in medical practice. This has
at least two major disadvantages. First, it creates an air of knowledge
exclusiveness and an accompanying atmosphere of intimidation and
pre-eminence in the team. Such biases are outrageous – from the very
beginning, mutual respect should be fostered. The focus of the decision-
making process involves an ethical and not a clinical basis (granted that
there is an important clinical component to the discussion) and, as argued
earlier, no team member can reasonably lay a claim to moral superiority.39
Indeed, it is the values and cherished goals of the patient around which
the discourse is generally
Foster an atmosphere of personal centred.
involvement with valuable input.
Second, throughout
Approach situation positively and the ethical decision-making
enthusiastically. process, it is very important
Meeting should be well focussed to remember that effective
- sidetracking and defocusing should and meaningful dialogue
be minimized through effective is only possible when
facilitation. everyone involved has a
The discourse, in style, expression reasonable and adequate
and terminology should be such that understanding of the actual
everyone, especially the lay person, discussion. Consequently,
could appreciate and comprehend. the discourse, in style,
expression and terminology
should be such that

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Pitfalls to Avoid misperceptions and a morally prejudiced upbringing.

It is possible for health care professionals to respond in one of (iii) Imposition of a Preferred Source of Morality.
four basic ways to ethical dilemmas in clinical practice. ‘Professional
ignorance/uncertainty’, ‘moral intuitive’, and ‘preferred source of This response to a moral dilemma means that the health care provider
morality’, are the commonest responses. A succinct discussion of each of utilizes what he perceives to be an adequate justification for making an
these responses will be undertaken in order to determine its advantages ethical choice, based solely on a personally preferred source, either
and impediments. The position taken here is that the further our society because of an ignorance of other legitimate considerations, or due to a
evolves from the traditional paternalistic model in medicine toward a dogmatic and rigid attitude. It can occur in both sole person decision-
more public and ‘democratic’ (that is, a collective and collaborative) making as well as in environment-specific decision-making. There is a
approach, the greater the thrust toward shared responsibility and plurality of legitimate ethical theories or sources of morality, and in this
accountability and, hence, an analytical decision-making process. Life approach decisions are the result of a staunch and obdurate affinity for
is dynamic and, undoubtedly, held sentiments are very important. It is a specific perspective, for instance utilitarianism or, quite commonly, a
crucial to remember that, in a constantly evolving world, an impartial particular religious belief system.
discerning process of ‘thinking through’ held sentiments enhances and
up-dates one’s moral position. (iv) The Analytical Approach: Bioethical Model.
It is necessary to use Bioethics in order to provide rationally
(i) Professional Ignorance/Uncertainty. defensible solutions (ensuring clarity, coherence, consistency and
A lack of ethical knowledge, analytical and facilitatory skills, as adequacy) to perplexing situations and quandaries effectively.40 Unlike
well as a lack in motivation to seek appropriate resources for assistance other very common ‘methodologies’ that are used to obtain answers, for
and guidance, may lead some health care professionals to either trivialize example, ‘intuition’ and ‘personal preference’ approaches, biomedical
the ethical problem, with the misperception that it would spontaneously ethics offers a systematic process that attempts to sift out biases,
resolve itself in time, or shift the focus from a moral (value) perspective prejudices, unjustifiable opinions, and irrelevance, and to ensure that the
to other aspects of patient care, for example, clinical or legal, and decision secured is the most morally weighted and rationally justified
resolutions are thence sought through these approaches. Inappropriate and under the given circumstances.
unjust consequences result – the patient and other staff members could
suffer unnecessary and prolonged emotional distress and processes. And,
the patient might well find himself/herself being prematurely discharged Pitfalls to Avoid
from the care of the clinician and/or facility, because of the inability to
effectively and adequately manage the perplexing situation. Ignoring/Marginalizing value issues

Clinicalizing value issues

(ii) Moral intuitive approach.
Moral intuitions are perceived as immediate and spontaneous Imposing personally preferred
sentiments. They are non-reflective, and all pervasive in the daily morailty
activities of most individuals, that is, moral intuitions are practical and
Using purely intuitive responses
action-guiding, especially when there is little or no time or, indeed,
(exept perhaps in emergencies)
desire for rational scrutiny. They tend to establish a prima facie case
for an evaluative situation being as it is intuited, that is, without any
rational inquiry, and this can be fraught with prejudicial propensities
and misleading. Moral intuitions, then, are fallible – they are vulnerable
to arriving at rationally unjustifiable conclusions through, for example,

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Fallacies clarify its use.

It is certainly beyond this handbook to provide instruction on Syntactical Ambiguity: This occurs when different interpretations of a
critical thinking and argumentation skills. It is very important, though, sentence result from unclear grammatical structure.
to note that reasoning is primarily based on sound argumentation. Fallacy of Vagueness: This occurs when a vague premise or conclusion
A valid argument is one where (i) the premises possess truth-value is advanced in an arbitrarily (and deceptively) precise way while
and are rationally acceptable, (ii) the premises logically support the attempting to maintain an illusion of a broad meaning.
conclusion, and (iii) only considerations relevant both to the justification Fallacy of Ad Hominem: This occurs when an attempt is made to
and rejection of the conclusion are taken into account. Here is a list of discredit an argument by attacking the character of the presenter of
common fallacies to be mindful of and hopefully avoid41: the argument instead of addressing the argument itself.
Fallacy of Ambiguity: This occurs when an expression can be understood Fallacy of Poisoning the Well: This occurs when a person attempts to
in at least two distinct ways, and there is no clear way to tell how discredit an argument by including irrelevant information instead of
it was meant within the context of an argument. Ambiguity can be focusing on the argument itself
either syntactic or semantic (see below).
Fallacy of Begging the Question: This occurs when the conclusion of an
Fallacy of Appeal to Ignorance: This occurs when either a conclusion argument is simply a restatement, usually in a different vocabulary
is said to be correct merely because there is no known evidence to or form, of one of the premises. It does not, therefore, substantiate
establish that it is not, or when a conclusion is said to be incorrect or justify anything.
because there is no known evidence to establish that it is correct. In
both cases, the lack of evidence is appealed to in support of some Fallacy of Confusing Necessary and Sufficient Conditions: This
conclusion. occurs when a necessary condition is presented as a sufficient one in
supporting some conclusion.
Fallacy of Appeal to Pseudo-Authority: This occurs when, in supplying
evidence for a conclusion, either (i) a recognized authority in one Fallacy of Deceptive Alternatives: This occurs when a premise
field is cited as providing evidence in another area, or (ii) when incorrectly suggests, explicitly or implicitly, that the alternatives
someone or something is assumed to be authoritative when in fact it mentioned are mutually exclusive or exhaustive of all possible
is highly controversial and questionable. alternatives relevant to the conclusion. This creates a false dilemma
by limiting viable options.
Fallacy of Appeal to Pity: This occurs to the extent that, instead of
giving evidence to support a conclusion, the person appeals merely Fallacy of Inconsistency Claims: This occurs when an argument
to the emotions of the receiver(s) to accept the conclusion. contains contradictory claims – a person makes a certain claim at
one time and its contradiction at another without providing reasons
Fallacy of Equivocation: This occurs when the conclusion of an for this change of position.
argument depends on the meaning of a single ambiguous expression
shifting between two or more definitions, within the argument. Is-Ought Fallacy: This occurs when a conclusion asserting what should
be the case is based solely on considerations of what is or has been
Fallacy of Fake Precision: This occurs when a claim purports to have the case. For example, to derive moral (value conclusions) directly
(empirical or statistical) precision that is practically impossible yet from empirical data without further analysis is highly suspect.
is still used as evidence.
Fallacy of Red Herring: This occurs when an attempt to discredit an
Fallacy of Neglect of Relevant Evidence: This occurs when pertinent, argument is made by including considerations that, while broadly
but unfavourable, considerations to an argument or conclusion are related to the original argument, are redundant to the specific claims
ignored or marginalized. of that argument.
Semantic Ambiguity: This occurs when a term has two or more distinct Fallacy of Simple Correlation: This occurs when it is assumed that a
meanings and the context in which that expression is used does not mere correlation between two phenomena is sufficient to establish a

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Making Ethical Choices Making Ethical Choices

causal relation between them. Personal Values

Fallacy of Slippery Slope: This occurs when it is asserted, without It is misleading to believe that there is a definite distinction between
adequate evidence or justification, that one event will necessarily private and professional morality. Ethical decisions made at work,
lead to another, and that this second will necessarily lead to yet home, or in church reflect one’s character, convictions, and conscience.
another in a chain of events until some final (usually very unpleasant) The personal values of all team members play an enormous part in the
situation is brought about. analysis and resolution of an ethical dilemma. It is possible to argue
Straw Man Fallacy: This occurs when an attempt is made to discredit that because the patient has most at stake in the situation – it is his/her
an argument by recasting it in a weak, exaggerated or foolish way physical and emotional health, welfare, and even perhaps death that will
not intended by the arguer and, then, attacking that refashioned be affected by the consequences of the decisions made – his/her values,
argument as if it were the original one. wishes, and preferences should rightly form a crucial aspect of the
Tu Quoque Fallacy: This occurs when there is an attempt to defend ethical decision-making process. However, it is extremely important to
an argument against attack by suggesting that the critic has done remember that while a patient has a right to seek treatment for a perceived
something very similar, if not the same thing – as if “two wrongs ailment as well as a right to veto or refuse a particular proposed course of
make a right.” treatment, he/she cannot mandate treatment.42

Wishful Thinking Fallacy: This occurs when desiring or believing that A patient’s autonomy is usually reflective of his/her desires, opinions
some claim is correct or incorrect is actually substituted for evidence and values. Undeniably, respect for patient autonomy is a cardinal
for that claim without adequate justification. biomedical principle. It asserts that persons should be completely free
(from coercion or compulsion) to act in accordance with their personal
beliefs, thoughts, desires, and values. Although it is a prima facie moral
principle, there are circumstances under which respect for this principle
may justifiably be temporarily suspended and overridden by competing
moral obligations. Therefore, respect for a patient’s autonomy is not an
absolute duty incumbent upon a clinician or facility. The Mental Health
Act acknowledges this consideration in the case of imminent danger to
oneself and/or to others.43
There are times when a patient’s needs conflict with his/her desires.
A typical example is the patient who requests and insists upon receiving
a prescription for antibiotics for his/her sore throat when, in fact, he/she
has a viral infection. Not only are the antibiotics not indicated, but they
might well be harmful to him/her, with short term adverse effects, as
well as harmful long-term consequences, for example, drug resistance.
And, requesting and even requiring a scarce resource for which no
funds are available is an example of a morally justifiable restriction on
a person’s autonomy. Clearly, the clinician has his professional integrity
and autonomy to respect and, in these situations, the decision to honour
these and to override the patient’s autonomy would be considered
ethically justifiable and appropriate. Despite the fact that it is the patient
who has most at stake in the situation, no team member should be
coerced or compelled to participate in any activity that clearly offends,
or is diametrically opposed to, his/her personal and professional value

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system. secure another clinician.44

Some clinicians perceive a tension between the notion that it is It is important to remember that a physician cannot abandon a
the physician who could possibly be held legally accountable (as the patient. This may occur when the physician severs the relationship with a
person who is responsible for the overall treatment of the patient) and patient without reasonable notice when the need for treatment exists and
the argument for the inclusion and equal weighting/consideration of is expected, when the physician fails to notify the patient of impending
the opinion and values of other legitimate members of the health care absences, fails to provide reasonable care and treatments, or any other
team. With the shifting paradigms in health care delivery, for example, improper withdrawal from the physician-patient relationship.45
with increased front-line health care professional empowerment and a
focus on a multidisciplinary team approach, it would be just and fair
that legal accountability and responsibility accompany the increased
shared professional and moral rights and obligations to patients. Such
an equitable distribution of responsibility with respect to the ethical
identification and resolution of ethical dilemmas is especially evident
if each member of the team is granted full participation membership.
Personal Values
In congruence with this diffusive responsibility, as argued earlier, there It’s a myth to think that one
appears to be a judicial shift toward holding health care institutions (rather can differntiate between “public
than individual clinicians) more and more accountable and responsible morality” and “private morality”
for the overall care of the patient.
Ethical decision-making is a collective and collaborative process. Moral decisions at work, home and
However, following the deliberation, it is perhaps the physician, as the at church seat in one’s conscience
‘team leader’ in clinical practice, who ensures that the chosen action is “The softest pillow to sleep on is a
implemented. In this sense, the physician’s position as the primary person clear conscience”
responsible for the overall treatment of the patient (within the facility and
in the everyday operation of treatment) would not be affected, and his
appreciation of the inclusion of other legitimate members of the health
care team in an effort to effect a morally justifiable and expeditious
course of action under the specific circumstances, would be nothing less
Proper Termination of a Relationship
than commendable. Patient is given reasonable notice
Furthermore, patients have an obligation to their clinicians to Patient is assisted in finding another clinician
consider the alternatives seriously, including identifiable expected Appropriate records and information are
consequences of each, as well as priorities set by their clinicians. They provided to the new clinician as requested by the
have a responsibility to take seriously the advice of the professional patient
whose expertise they seek. Of course, they have a right to second/
alternative opinions. However, once agreed to engage in therapy with
a clinician, a tacit contract is initiated, and both parties should respect
each other’s duties and obligations. It has been argued that the clinician
may not terminate the clinician-patient relationship unless: the treatment
modality is completed by its own nature; the patient terminates the
relationship; there is a mutual agreement to terminate the relationship
(for whatever reasons); and the clinician informs the patient of his intent
to terminate care sufficiently ahead of time, thus allowing him time to

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Moral Reasoning vii) Understanding, respect and tolerance – moral judgements in health
care invariably involve moral diversity and sensitive matters that
Moral reasoning, that is, assessing arguments to determine goodness/ impact all stakeholders. Mutual respect and tolerance are therefore
badness, rightness/wrongness, fairness/unfairness, can be very complex. extremely important, even when we disagree with the values, beliefs
Our sense of what is moral is often fraught with emotions and perhaps and judgements of others. Moral reasoning is to a great extent an
unreflective opinions. This is why it is especially important to critically activity that includes learning from each other.
evaluate value-laden situations and to use rigorous moral reasoning skills
in arriving at moral judgements. While it is beyond the purpose of this viii) Generalization of moral judgements – one of the litmus tests for
handbook to undertake an analysis of such skills, it is noteworthy that moral judgements is that what we consider right (or wrong) for a
moral maturity is a crucial element in moral reasoning.46 This may be person under certain circumstances must also be right (or wrong) for
described as characteristics exemplified by a morally mature, reasonable others under relevantly similar circumstances.
person. These include the following:
i) Justification by appeal to principles – it is important not to simply
appeal to personal beliefs and opinions but instead to some general
justificatory principle.
ii) Independence of judgement – we need to recognise that we must
accept personal responsibility for the moral judgements that we
make or espouse, rather than to hold moral judgements because of
someone else’s authority.
iii) Consistency – we should be consistent in the moral positions that we
hold – between different moral issues and between our actions and
judgements.
iv) Awareness of complexity – we should acknowledge the complexity
of moral issues and indeed principles. What, for example, do the
moral maxims “respect all life” or “be fair” really mean? As Aristotle
warned about ethics, “Don’t expect any more precision than the
subject matter will allow.”
v) Recognition of our fallibility as human beings – we need to recognise
that there is always the potential for personal biases and prejudices,
albeit non-malicious. The morally mature person will be open to the
fact that further reflection, dialogue and discourse may lead us to
modify our positions.
vi) Factual element – it is important to realise that we need to seriously
consider the facts that pertain to the situation. In health care, these
would include investigative and diagnostic information. Indeed, it
might become necessary to seek the judgement of ‘experts’ in the
factual realm; however, it is crucial to remember that the moral
domain, while incorporating facts (and probabilities), is a separate
entity.

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The Law
It is very important to consider what the legal components of the Common Areas of Malpractice
case might be. The laws of the land should be adhered to. Laws attempt Improper diagnosis of the patient
to reflect what is generally considered morally acceptable in a particular
Improper treatment of the patient
society. This is not to suggest that all laws are necessarily moral, and we
have seen the enactment and implementation of morally repugnant laws Failure to protect the patient from self harm
over the centuries.47 Indeed, it could be argued that the law is constantly Sexual exploitation of the patient by therapist
trying to keep apace with morality. Casuistry, through precedent-setting
medico-legal cases, can provide effective and invaluable direction with Regulatory improprieties (improper informed consent,
respect to dynamic societal values and legal constraints.48 intrusion of patients’ rights, confidentiality issues, and
improper commitment procedurres)
It is of paramount importance of health care professionals and
administrators to consider their legal duties and obligations to all
stakeholders. For example:
1. The duty to attend
2. The duty to consult and refer Professional Codes of Ethics
3. The duty to diagnose Professional codes of ethics, as a set of general guidelines, are
necessary in providing certain parameters in the patient-health care
4. The duty to inform the patient professional relationship and interaction. They generally suffice
5. The duty to obtain patient’s consent to treatment in fulfilling this purpose. However, there are several significant
6. The duty to provide treatment disadvantages that render them ethically inadequate. First, professional
ethics usually have an underlying set of presuppositions that are,
7. The duty to use care themselves, suspect under closer scrutiny. For example, the Hippocratic
8. The duty to instruct the patient Oath emphatically forbids euthanasia and abortion without offering any
justification whatsoever for these categorical prohibitions.
9. The duty to maintain confidentiality
Second, professional codes of ethics tend to be profession-specific,
10. The duty to take responsibility for associates and staff
for example, a code for doctors, one for nurses, another for psychologists,
11. The duty to keep medical records and so on. Generally, each professional code seeks to promote the
12. The duty to give evidence welfare of its membership, and it is possible to have conflicts between the
various codes of professionals who care for the same patient. A corollary
13. The duty to be licensed is that the primary focus of professional codes of ethics is toward their
Hospital liability for the care of a patient generally arises from a members, with patients’ welfare as secondary interest. Better-informed
breach of contract or by an act of negligence (by its staff and/or through patients in today’s society are demanding that patients’ values (rather
defective equipment). Claims may also arise from the hospital’s selection, than professional values) play a predominant role in professional codes
instruction, and supervision of staff, as well as the care and treatment of ethics.
provided. The expectation is that patients will be cared for by skilled Third, a list of a professional code of ethics cannot provide solutions
persons who will attend and treat them.49, 50 for the quantity of moral dilemmas that are pervasive and inherent in the
complex grey areas of real life situations, involving unique individuals
and circumstances, for instance, when there are conflict of interests.51
Generally, professional codes of ethics are inadequate in directing a
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clinician’s actions in complicated situations or in the effective and ethically Institution’s Mission,Values, Policies &
justifiable means of resolving a moral dilemma. These codes need to be
flexible in order to ‘prioritize’ principles when they conflict, and they Practices
need to be binding upon the professional in order to be meaningful and
practical. What ought to be borne in mind, is that, at its best, professional “Will not the knowledge of [the good], then have a great
codes provide a rough guideline for a specific group of professionals influence on life? Shall we not, like archers who have a
within the context of, and relevant to, that particular profession. In this mark to aim at, be more likely to hit upon what is right?”
regard, it is possible to find the professional code of ethics from one (Aristotle)53
professional organization conflicting with that of another, and with
each adamantly adhering to its own professional code, no resolution is Institutional policies and practices are sometimes developed with
forthcoming. Additionally, professional codes of ethics generally express the intention of protecting against legal action, and are only too often
the values of the profession and not the values of any particular patient or followed in a ritualistic way. It is crucial that policies and practices, and
of society as a whole. Not unlike the law, professional codes of ethics are indeed, those who implement them, foster a climate of open dialogue and
certainly not immune from acts that constitute moral indignation.52 collaboration. In particular, competent patients should never feel that they
would be abandoned or isolated because of their decisions. Advocating
for patients involves supporting them in the decisions that they make,
even when members of staff disagree with their choices. The institution
should have an easily accessible and fair mechanism for patients and
Laws & Professional Codes of staff to resolve disagreements and conflicts when they occur.
Ethics Health care administration is a very complex phenomenon, and it is
Laws aren’t necessarily moral; often not the purpose of this handbook to offer an exposition and analysis of
too broad duties and responsibilities (moral, legal and social) that arise from sound
business or organizational ethics. However, it is important to appreciate
Codes aren’t necessarily moral; very that relationships within organizational structures are generally based on
general; little direction in prioritizing intrainstitutional socialization to values and norms, and ideal employees
conflicts of principles or interests; are viewed as those who are congenial with its operations in every way.54
profession-specific; primarily serves Irrespective of the employees’ response – either rejection of values and
interests of profession norms, or engagement in only chosen values and norms, or conformity
to all values and norms – the fact remains that an institution’s mission,
policies and practices represent extremely powerful constraints for health
care providers, the employees of the institution.
From an ethical perspective, it is crucial to engage diverse moral
perspectives in the development of pivotal values and philosophies, rather
than to simply attempt to align employees conduct with organizational
norms and standards. Rigid adherence and conformity can sometimes
override realistic appraisal of alternative perspectives through
“groupthink”, thereby hindering growth and success.55 This begs the
pressing question concerning how administrators and managers respond
to the inherent ambiguities and uncertainties in the ethical terrain of
institutional norms, values and customs.
It is extremely important to remember that institutional values,
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especially as they pertain to health care, should be viewed as also having Ethical Principles & Guidelines
intrinsic worth (such as justice, honesty, and respect for human dignity),
rather than simply primarily serving some utility. In a context of potential
for divided loyalties, it is vital to have a mechanism that would ensure
Fiduciary Relationship
a just balancing of legitimate interests; for instance, the zealous pursuit The clinician-patient relationship is rooted in a moral foundation. In
of efficacy and revenue must be tempered with honouring social and other words, it is based on the fiduciary understanding – trust, good faith,
moral responsibility to all stakeholders. Most of the moral principles and confidence – that the clinician and institution will consistently pursue
that govern the conduct of health care professionals will also apply to and safeguard the patient’s well-being and best interest. Clinicians acting
the health care institution. In addition, general moral principles (such as fiduciaries are not permitted to use the professional relationship solely
as honesty, reliability, integrity, justice, and common decency) form the for their personal benefit, and they should deliberate and act extremely
bedrock for just and fair dealings with all stakeholders. carefully in matters relating to “double agency” (to simultaneously
serve the patient and an agency, institution or society.56 Several moral
Frequently, an institution’s ‘mission’ had been developed without
principles and duties govern this advocacy and fiduciary alliance.
adequate input and involvement from front line health care providers, yet
they often serve as very decisive considerations in the courses of action
that are available to health care professionals. Sometimes, of course, 1. Ethical Duty to Patients
ethical difficulties may themselves arise from conflicts between the a. Respect for Persons and Autonomy
institution’s mission and interests and the professional’s perceived duties
and obligations to a patient and even patients in general. These powerful Every patient has a right to be treated with respect, dignity, and worth
influences do affect one’s ability to act ethically, and it is crucial for as a human being. This involves respecting the person’s ‘autonomy’ or the
health care professionals to consistently maintain fiduciary integrity with right and liberty to determine and pursue his/her cherished values, beliefs,
their patients. goals and preferences in life. Autonomous persons act: (1) intentionally
(2) with understanding, and (3) without controlling influences that
determine their action. Responsibilities accompany rights, and patients
are expected to act responsibly in their right to autonomy; for instance,
they must honour the rights of everyone else. Patients have a right to
safety, privacy and confidentiality. The law and ethics rest the onus on
the violators of patient autonomy to justify their action with great moral
rigour.

b. Beneficence
Health care professionals are bound by the ethical duty and
commitment to actively pursue, promote and protect the welfare, well
being and best interest of their patients. Beneficence must also be pursued
in a compassionate, effective and timely manner. Patients’ autonomy and
best interest always comes first, and patients are strongly encouraged to
make fully informed choices. Invariably the patient has most at stake and
should be incorporated, as best as possible, in pertinent decision-making
processes.

c. Non-maleficence
“Primum non nocere” or “above all do no harm.” Health care

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professionals are bound by the ethical duty and obligation to not cause, by their employment (job description) and within the constraints of the
indirectly or directly, harms or evils to patients. An exception is when law and sound ethical conduct.
harms are calculated and greater benefits are anticipated on a harm-
benefit analysis, and when the patient agrees to run the risk of the harms. 5. Ethical Duty to Employees
An example of such a harm would be the adverse effects of a medication,
Employers have a duty to provide a safe, respectful and pleasant
investigative or treatment procedure.
work environment for their employees. Employees have a right to clear,
d. Justice coherent and reasonable job description, as well as entitlements to
competitive wages and benefits, to meaningful input in situations that
Health care professionals are bound by the ethical duty to allocate affect their work, and to respectful and constructive feedback with regard
and use all health care resources efficiently and effectively, with justice to their performance. Employers also have a responsibility to employees
and fairness to all stakeholders, and with full regard for individual worth to provide opportunities for continuous personal and professional growth
and dignity. It is important to remember that health care professionals and development. Growing and thriving environments excel in honest
are, like administrators and policy makers, gatekeepers to limited health and respectful communication and treatment of one another.
care resources. Admission criteria should reflect acceptable practices
regarding fair access to care and treatment, and therapeutic practices
6. Ethical Duty to Legitimate Third Parties
must carefully balance benefit-burden analyses.
There lies an ethical duty and obligation to collaborate with
2. Ethical Duty to Community/Society/Humanity legitimate third parties such as significant others, government agencies,
health care institutions, and insurance companies, in an effort to promote
Health care professionals and administrators are bound by the and protect the interests and well-being of our patients in a respectful,
ethical duty and obligation to consider the well being and safety of just, efficient and effective manner.
others, especially when serious risks or harms are anticipated.57 There
also exists a general responsibility to promote health and happiness and
7. Ethical Duty to Oneself & One’s Profession
to ameliorate pain and suffering as a service to humanity. In part, this
can be achieved through the pursuit of insights into, and treatment for, Health care professionals should realize a moral responsibility for
diseases and disorders through education and research. Research will continuous growth and development in their personal and professional
always be conducted according to strict ethical codes of conduct. lives. The health care provider role requires that their conduct reflect
moral sensitivity and maturity, mutual respect, professional competency,
3. Ethical Duty to Colleagues sound reasoning and compassion, and that they stay abreast of
developments in the art and science which they practice. In this way,
Health care professionals have an ethical duty and obligation to they can be faithful to their trust – to provide the best possible care and
work collaboratively, as a multidisciplinary team, to protect and promote treatments to patients, to maintain personal and professional integrity,
the health, well being and interest of patients. In so doing, they have a and to serve their community and mankind.
responsibility to respect the professional competencies, values and moral
convictions of each other. Team allegiance in team decision-making is
Ethical Principles
also extremely important.
Respect for Persons and Autonomy
4. Ethical Duty to Employer Beneficence
Employees should recognize the ethical duty and responsibility Non-maleficence
to serve their employer as trustworthy and committed agents,58 acting
Justice
consistently with the values and philosophy of the institution, and
promoting the institution’s mission and legitimate interests as required

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Making Ethical Choices Making Ethical Choices

The Virtues virtue of empathy (or feeling for another), and involves the motivation to
decisively act to relieve grief and affliction. Integrity is the willingness
(complement Ethical Principles) to develop well-calculated ethical and clinical judgements in an effort to
Health care practice includes and transcends the adherence to certain preserve and promote the patient’s best interests. The virtue of justice is
moral maxims and legal principles. Indeed, the law simply sets the bare of paramount importance in all aspects of social, economic, and political
minimum for acceptable practice. Virtue ethics places greater emphasis life, and health care is no exception. We are faced with the harsh reality
on the character than on the actual action of the person. Instead of asking, that we have limited resources, and how we allocate these is certainly a
for example, “what should I do?” virtue ethics mainly asks “what kind challenge that we all face.
of person should I be?” According to the Father of Philosophy, Aristotle Health care professionals who have internalized these virtues into
(384-322 BC), the character that has assimilated the primary virtues will their characters and who use universal moral principles as guiding
consistently deliberate and act morally right.59 Consider, for example, precepts stand a good likelihood of consistently acting with the best of
how cold, distant and inhospitable health care delivery would be in the motives and using morally justifiable means aimed at the most desirable
absence of care and compassion to a distraught family whose teenage consequences. It is this noble character that forms the basis, the guarantee
child recently committed suicide. if you will, for the trusting relationship which is crucial to the health care
Aristotle defines virtue as a habit or disposition of the soul and process.
involves both feeling and action, and which seeks the mean in all things We ought to remind ourselves that there exists an enormous
relative to us (as the prudent man would define the mean).60 For example, imbalance of power in the patient-clinician relationship. The clinician
a deficiency of regard for other people is seen as exploitation, an excess possesses the expertise that patients require in order to restore their health
as deference, while the mean is viewed as respect. Virtues, according to and to reduce, if not ameliorate, their pain and suffering. This places the
Aristotle, leads to happiness and human flourishing. dominance of power and authority in the hands of the clinician, and he
The virtue of self-effacement is the willingness to routinely set or she can either use it wisely, for good, or poorly, and bring about great
aside differences and considerations that should either not count or be harms and evils. So much is riding on the good will and integrity of
kept in rightful perspective in the care of the patient. These include clinicians in this advocacy and fiduciary relationship.
religious differences, personal pecuniary benefits, and sexual attraction.
Should the health care professional’s own interests become his primary
focus of attention, albeit unwittingly rather than surreptitiously, it is not
uncommon to find the patient’s best interests slip away. The Virtues
The virtue of self-sacrifice is the willingness to risk one’s own (complement ethical principles)
interests, within reasonable limits of course, and to make personal
sacrifices in the pursuit of the health, best interests, and life of the patient. Examples are Integrity, Compassion,
Adhering to these virtues would help to place moral reins on the conduct Justice, Self-sacrifice and Self-
of clinicians, thereby harnessing the natural inclination to focus on effacement
themselves in favour of the interests of the patient. As the Medical Oath “Just like the sight of one sparrow
of Moses Maimonidies states: “Do not allow thirst for profit, ambition does not Spring make, so too
for renown and admiration, to interfere with my profession, for these can one good deed does not a good
lead astray in the great and noble task of attending to the welfare of Thy character make.”
creatures.”
Other associated virtues are compassion, integrity, and justice.
Compassion is the willingness to identify and expeditiously respond to
another person’s suffering and distress. It incorporates and transcends the

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Making Ethical Choices Making Ethical Choices

Ethical Decision-Making Model Making Sound Ethical Choices in Health Care: an Analytical
Decision-Making Model
“But in order to pave the way for such a sentiment (that is,
one that forms the basis of a moral judgement) and give
a proper discernment of its object, it is often necessary, Perplexing Situation
we find, that much reasoning should precede, that nice
distinctions be made, just conclusions drawn, distant Inter-disciplinary Team &
comparisons formed, complicated relations examined, and Patient Meeting
general facts fixed and ascertained.” David Hume61
Problem Resolved Problem Unresolved
The process starts with disequilibrium in the integrity of the milieu.
Preventative Strategies
In practice, a member of the team, the patient or a member of his/ Inter-disciplinary Team
Meeting (include “Impartial
her family, perceives disequilibrium in the milieu – seemingly a dilemma Facilitator” if possible)
has arisen. A member of the team is uncertain as to what the next course “Context Constraints”: time,
resources, prof. codes of ethics,
of action should be, or someone is unhappy/distressed with a particular Stage 1
Gather Information. Identify
& inst. policies and practices

situation, and appropriate help is sought – a concern or complaint is Stakeholders,Values and

lodged, officially or unofficially. The situation has no clear alternatives, Brainstorming
“Contextual Constraints”
Moral Intuition
has far-reaching implications, involves a number of people (directly and Stage 2
indirectly), and has a perception of unresolvability through an identifiable Separate Clinical, Legal &
clinical solution. The specific nature of the problem may or may not be Ethical (Value) Facets
identified at this point. Ethical Nature Clinical/Legal
The matter is taken to the team for discussion. The lodger of the Nature
concern should be accorded full respect for his/her feelings and opinions. Stage 3
Duties & Obligations Respect for autonomy,
beneficence, non-malefi-
The situation should be treated with a sense of urgency and with full to all Stakeholders cence, justice. Appropriate
Action
confidentiality. The primary person who lodged the concern/complaint
Stage 4
should provide a description of the perceived difficulty to the team.
Conflict of
Nature of principles/ Resolved Unresolved
Either the team offers a reasonable and ready explanation or solution to Specific Conflict interests

the satisfaction of the individual, or identifies the existence of a medico- Stage 5 Preventative
ethical dilemma. If the existence of a dilemma is confirmed, then the Critical Analysis - Strategies
Viable Alternatives
team proceeds to the First Stage in the Ethical Decision-Making Process. Re-examination
of Information
Deontological (prima facie duties)
Juxtapose with & teleological - short & long term
Team involvement is a nothing less than a collective and collaborative (esp.Values) Values & Prioritize consequences.
Resolution Strategies
process. with Preferential Scale
Stage 6
Stage 7 Action Implementation Consider who, when, and how to implement.

Stage 8 Dilemma resolved? Other problems created?

Evaluation of Outcome Need to revisit?

Stage 9
Preventative Strategies

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Making Ethical Choices Making Ethical Choices

Stage One: Recognition of Dilemma & Comprehensive himself/herself (as defined in the Mental Health Act), then
Information Gathering, Including Personal Values and there is need to honour the duty to rescue and/or protect.
Contextual Constraints. Q: Are there reasons to suggest that the patient may not be
Gather as much information as possible and, in so doing, ensure that mentally competent to consent to, or refuse, care and
nothing relevant gets missed. All judgements should be suspended, and treatments?
members ought not to rush to conclusions. Moral intuitions play a great Note: The assumption is always that the patient is mentally
part at this stage. Brainstorming is very important in order to explore competent. If the patient is unable to provide consent or lacks
and generate a wide variety of possibilities and options. Professional and ‘capacity’, then one needs to follow an Advance Directive,
personal values, opinions, ideas, and feelings are voiced. It is imperative proxy, or Power of Attorney for Personal Care. If none of
to foster an atmosphere of mutual trust, respect and co-operation. these exist, then elect one (in accordance with the Mental
Remember that there may be ambiguity, uncertainty and perhaps fear, Health Act). It is important to remember that a patient’s
anxiety and resentment. Moral judgements made in a professional seemingly irrational decision does not, by itself, constitute
capacity would affect one’s conscience, one’s private sphere. Ideally, the incompetence.
team aims at arriving at consensus in decision, and this is only attainable
when team players are satisfied that their respective positions have been Q: Are there rationally justifiable reasons why the patient’s
heard, appreciated, and critically evaluated in the process, and they have preferences might be overridden?
in front of them a decision that they could live with. Note: The onus is always on the health care professional(s) to justify
any overriding of patients’ values, wishes and preferences.
1. DILEMMA
Q: Why is there disequilibrium in the patient-treatment team 4. TIME
relationship or dissension amongst team members with Q: Does this constitute an emergency situation (as defined in the
regard to patient care and treatment? Mental Health Act), and how much time is there to arrive at a
Q: What is causing the qualm, uneasiness, or apprehension? decision?

Note: Confirm that a dilemma exists. Something is amiss, and the Note: If classified as an emergency, then act with prudence to rescue
team doesn’t really know what to do. It probably doesn’t and protect if unable to secure consent from the patient or
even know exactly what is the problem. The team perceives Substitute Decision Maker, and if no Advance Directives
at least two alternatives from which to choose, but cannot are available. Further deliberation is required after the initial
agree on a choice. intervention in order to determine an ethically acceptable
course of action. How might another reasonable clinician/
2. STAKEHOLDERS treatment team act under similar circumstances? Casuistry
can be extremely useful in an emergency situation, because it
Q: Who are the legitimate stakeholders, and what has each at
provides the team with past precedent-setting cases and their
stake?
outcomes.
Note: The primary stakeholder is invariably the patient. Other
stakeholders might include significant others, health care 5. RESOURCES
professionals, the hospital, others (co-patients, society, Q: What are the relevant resources at the team’s disposal?
insurance company, employer, etc.)
Note: If the resources (expertise/competency or material) are
3. PATIENT’S VALUES, WISHES AND PREFERENCES inadequate or unavailable resources then a consultation and
perhaps transfer to an appropriate clinician and/or facility
Q: What are the patient’s values, wishes and preferences?
might be necessary.
Note: If the patient is suicidal or homicidal or unable to care for
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Making Ethical Choices Making Ethical Choices

6. INFORMATION GATHERING are duly considered in courts of laws, “in an effort to give
Note: There is a need to have a thorough case description (includes substance to the moral convictions of reasonable or common-
culture, religion, language, etc); medical and mental illness sense people.”63 This is especially relevant in the discipline
(includes history, investigations, severity, prognosis, etc); all of psychiatry, because of the extensive usage of elusive
therapeutic alternatives available to manage the condition, and ill-defined terms and concepts. If the dilemma involves
including probabilities of each with its risks and benefits, a predominantly legal issue, seek direction from hospital
as well as the ramification of non-intervention. Clarify what policy, Risk Manager, or legal counsel, and act with team
information is factual and what is uncertain/undetermined. consensus ideally.
Q: What is the clinical dimension to the dilemma?
7. PROFESSIONAL CODE OF ETHICS
Note: Consider current medico-scientific data as they apply to the
Q: What guidance, if any, is provided by the applicable code(s) case. It is very important to heed Howard Brody’s caution
of ethics? that “With an ethical dilemma, we can have all the data in the
world, and we still cannot arrive at an answer until we come
8. THE LAW
to grips with our values and make some value judgements.”64
Q: What guidance, if any, does the law provide under these If the dilemma involves a predominantly clinical issue,
circumstances? collaboratively (team and patient and/or Substitute Decision-
Note: It’s usually very helpful to have a knowledge of precedent- Maker) determine the most appropriate course of action.
setting cases (casuistry) Consider if you might benefit from a medical/psychiatric
consultation. Act with team consensus ideally.65
9. HOSPITAL POLICY & PRACTICES Q: What is the ethical dimension to the dilemma?
Q: What are the institution’s current policy and practices in these Note: It is important to remember that anything associated with
situations? values – rights and entitlements, duties and obligations, as
well as justice and fairness – are inherently ethical. If the
Stage Two: Attempt to Separate the Clinical, Legal and dilemma involves a predominantly ethical (value) issue,
Ethical Components then progress to Stage Three. Consider a consultation from a
Having gathered as much pertinent information as possible, the Bioethicist (if available).
team proceeds to identify the nature of the difficulty. There are usually
clinical, legal, social, policy and procedural considerations that are Stage Three: Pertinent Ethical Duties & Obligations
intricately interwoven with the ethical component in medico-moral Specify the ethical duties and obligations that pertain to the case,
dilemmas. Serious attempts should be made to tease these apart, within noting how they apply. It is important to remind oneself that it is the
reason, in order to ensure clarity of consideration. patient who usually has most as stake. Values are only meaningful in a
Q: What is the legal dimension to the dilemma? context of duties and obligations. Pertinent ethical principles include:
Note: Consider if the law of the land has been, or stands to be, (1) Respect for autonomy – to respect the individual’s right and liberty
violated; for example: does the patient meet the criteria for to make choices in accordance with his personal wishes, values and
dangerousness or is seriously vulnerable; has there been cherished goals in life). (2) Non-maleficence – to do or cause harms/evils
an allegation of child abuse or sexual misconduct; or does to the patient (on balance with benefits). (3) Beneficence – to actively
it involve a patient who is impaired to drive a vehicle/fly a protect and promote the patient’s well-being and welfare, primarily as
plane?62 In medical practice, laws usually have qualifying perceived by him/her. (4) Distributive justice – pertains to the just and
phrases that allow for value judgements. Concepts like fair distribution of finite health resources.
‘reasonable’, ‘sufficient’, ‘lawful excuse’, and ‘unwarranted’ Please note the prima facie nature of these duties and obligations.
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Making Ethical Choices Making Ethical Choices

This means that it is possible to override a certain duty by another, Q: Might the situation be such that a team member (or the
provided that there are rationally justifiable reasons to believe that the hospital) is simply failing to honour a specific ethical
latter should have priority under the circumstances. obligation to a legitimate stakeholder?
Q: What is the role of each stakeholder? Note: Health care professionals are generally very well meaning,
Note: The role of each stakeholder should be identified in order to but it is conceivable that sometimes they might fail to identify
ensure clarity and consistency. and honour specific duties and obligations to their patients,
albeit unwittingly.
Q: What are the treatment team’s duties and obligations to the
patient, the patient’s immediate family, potential patients, Stage Five: Critical Analysis & Viable Alternatives
and society in general?
Stages 5 and 6 are closely related. The team progresses to a critical
Note: Health care professionals’ primary obligation is to their analysis of the implicated duties and obligations. Further information
patients. gathering and clarification might become necessary. One needs to employ
Q: Likewise, what are the hospital’s duties and obligations to rationally justifiable means of ‘prioritising’ those ethical principles that
each of the above? conflict.
Q: What are the patient’s special responsibilities in his/her care Individuals from the team share their rationales for the positions
and treatment process? that they tend to favour. Following this, a brief re-examination of these
Note: Responsibilities accompany rights, and these should be rationales is crucial because, not surprisingly, they might very well
identified as they pertain to the issue at hand. become modified in the process.

Q: What obligations exist to legitimate third party stakeholders Examine all viable alternatives, including the option of delayed
(such as society and significant other/s) as they pertain to this and non-intervention. Take into account the foreseeable consequences,
case? short and long term, of all viable possibilities. These necessarily include
all anticipated goods/benefits as well as all anticipated harms/evils. The
probabilities of these are also crucial considerations.
Stage Four: Identification of Specific Conflict
It would be easier to initially exclude the alternatives that are totally
Having determined the specific duties and obligations that are
unacceptable. Develop a list of all ethically justifiable resolutions from
pertinent, it becomes necessary to specify, as clearly as possible, what
the most desirable to the least. In so doing, juxtapose selected viable
conflict exists, or whether there is a perception that someone is failing to
alternatives with pertinent ethical duties and obligations or principles.
discharge his/her obligations adequately and effectively.
Caution: Scrutinise for clarity, congruence, consistency, coherence,
Q: What is the nature of the conflict – might it be interpersonal
and adequacy.
or even institution-based?
Exclude deficient alternatives. The team needs to reach consensus.
Note: Consider if the dilemma might have resulted from personal
Dissenters might wish to drop out of the team at this stage of the process
conflicts within the interdisciplinary team, between the
if their moral positions are hopelessly irreconcilable with the preferred
patient/significant other and the treatment team, or between
alternatives.
the treatment team and the institution itself.
Q: What ethical principles or interests are in conflict in this Stage Six: Resolution Strategies with Preferential Scale
situation?
Rank the list of viable alternatives according to those choices that
Note: Consider if there might be a conflict between beneficence appear most desirable (according to the criterion already specified). This
and respect for the patient’s autonomy, or between respect is a particularly important stage.
for patient autonomy and a perceived obligation to society.

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Making Ethical Choices Making Ethical Choices

Q: What choice is most congruent with the patient’s wishes, treatments involve some harms/evils, for example, adverse effects. One
values, and preferences, and what reasons, if any, exist to must always weigh these anticipated harms/evils against anticipated
suggest that these should not be honoured? benefits, before implementing a course of action.
Q: What harms/evils should one be avoiding/preventing/ Sometimes, a reasonable compromise is to undertake an acceptable
removing? How realistic is this? course of action for a trial period, then reassess and re-evaluate efficacy
Q: What benefits should one be aiming towards? How realistic is and sentiments held by major stakeholders.
this? There should be a fair process for stakeholders to resolve
Q: Have any promises been made (that require honouring)? intransigent disagreements and conflicts, and this usually involves an
ethics committee, ethicist, or mediator.
Q: Would staff be acting paternalistically, and is this rationally
justifiable? Documentation is of paramount importance. Very careful
documentation of the content of all meetings and proceedings, including
Q: Would anyone be exploited in the process and, if so, exactly names and roles of all participants should be undertaken.
whom and why, and how can this be avoided?
Caution: Examine for clarity, coherence, consistency, congruence,
Q: What choice is most likely to offer the best overall and adequacy. Briefly check over the process to ensure that nothing
consequences, short and long term? pertinent was excluded.
Q: What choice is most likely to prevent the most harm, short
and long term, to stakeholders, especially the patient who Stage Seven: Action Implementation
invariably has most at stake? Before you attempt to implement the consensually-arrived at
Q: Would any of the proposed choices violate the institutional decision, it is important to answer the following questions:
policies and values, the law and professional codes of Q: Who is most appropriate to implement the choices arrived at,
ethics? and why?
Q: What choice would all stakeholders be most willing to live Q: When is the best time to implement the decision, and why?
with?
Q: When do you expect to see anticipated results?
Q: What choice would serve as a good example for others in a
similar situation to follow? Under most circumstances, no person should be expected to
implement a decision that he/she cannot live with. However, this maxim
Q: What choice is most justifiable by appealing to universal must be tempered by the principle that no immediate harms/evils would
ethical principles rather than personal preferences? befall the patient by one’s non-participation. You do have certain duties
Q: What do you honestly believe another reasonable group of and obligations to your patient, and these must be carefully considered
individuals would choose given the same circumstances? when attempting to make a personal appeal to your conscience.
Q: What if the staff and patient roles were reversed?
Stage Eight: Evaluation of Effectiveness
Q: Is there consensus that the anticipated end justified the
proposed means in this particular case? Q: Were the effects from the intervention those that were
expected, and did the decision resolve the specific dilemma
Juxtapose each chosen and ranked alternative with the patient’s that one was faced with?
values, beliefs and goals as determined directly from the patient (or from
a duly elected substitute decision-maker). Rank order those alternatives Q: Did the results occur within the time frame anticipated?
that are most congruent with the patient’s own moral position. It is Q: Are there other consequences that were unforeseen, and
important to remember that in health care practice most care and were new difficulties created? Might these require further

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deliberation and intervention? Conclusion

Q: Was this decision the most ethically justifiable under the Clinical practice continues to be replete with ethical quandaries.
circumstances? Individuals involved in health care systems and delivery – clinicians
and administrators alike – are grappling with new medico-technological
Stage Nine: Preventative Strategies advances, changing societal values, attitudes, and expectations and a
This is perhaps one of the most important stages in the process of rapidly increasing awareness of limited resources.
ethical decision-making. This handbook offers a comprehensive, readily applicable and
Q: What can be learnt from the dilemma? philosophically sound model that provides guidance in identifying
and resolving ethical quandaries in the care delivery process, both
Q: What factors contributed to the dilemma?
administratively and clinically. In so doing, the authors have explored
Q: Are there problematic policies and procedures? changing paradigms in health care delivery with their new moral demands
Q: Is there a need to modify current policies/procedures/ and challenges, as well as far-reaching ramifications that eventually affect
guidelines in order to prevent a recurrence in future? all stakeholders – patients, their families, clinicians, administrators and
health care policy makers, and society at large.
It would be folly to believe and expect that the facility, clinician,
or care team could foresee every problematic situation. Because we are Morally reprehensible decisions are avoided, and the chances
dealing with rather elusive and changing phenomena such as values, of arriving at rationally justifiable choices are significantly increased.
convictions, expectations and desires, ethical quandaries will arise in Litigation consideration is a very important factor, and because it is
the delivery of health care. However, once a dilemma occurs, we must intimately intertwined with moral accountability in health care, litigious
deal with it ethically, promptly and adequately. We must then critically situations are greatly reduced with a patient-centred, multidisciplinary
examine the entire circumstances of the situation in order to determine team approach.
the best strategy to prevent a recurrence. In this regard, the patient’s This integrative, eclectic procedure initially involves a respectful,
input would be invaluable. focused, perceptive and sagacious discourse amongst all stakeholders,
then progresses toward a pursuit and reconciliation of common threads
of moral agreements. Consensus is enhanced, and the facilitated decision
is one that most, if not all, affected individuals could live with. In
this way, no individual is coerced or compelled to act against his/her
conscience. Allowance is left for dissenters to opt out should their moral
positions be hopelessly irreconcilable with the decision of the rest of the
team. (Prior to this, though, they would have considered their duties and
obligations, not only to their patient(s) and significant others, but also to
their colleagues and other stakeholders.)
An alluring aspect of this model is its democratic thrust toward
decision-making in the clinical setting. It is consistent with liberal
democracy’s ethical norms and values. Major advantages to this
democratic impetus are collaborative, legitimate and committed
involvement by all pertinent players as well as shared responsibility
throughout the decision-making process. Through this involvement, the
values and opinions of all legitimate principals are duly considered and
form a vital component of the decision-making process. Thus, the most
rationally justifiable decision – the ethical choice – is yielded.
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Making Ethical Choices Making Ethical Choices

Case Study failure to rescue.

The patient’s current wishes are not to eat or drink. The patient denies
A starving patient with anorexia who refuses nutrition or being suicidal or of this being her plan to die. Yet, the patient’s current
hydration course will inevitably lead to her demise. There seems to be a lack of
congruence between the patient’s beliefs and wishes and the decision
Miss Jones is a 45 year-old single woman with a 12 year history of
she is currently making. In determining capacity, one of the criteria is
severe anorexia nervosa. She was admitted because of ambivalence about
to ensure that the patient possesses an understanding and appreciation
life and rapidly decreasing weight – 69 pounds, which is approaching a
of her illness and the consequences of each viable alternative including
dangerously low level given her height. Miss Jones is only ingesting
delayed and non-intervention.
small amounts (sips) of water. She denies active suicidal ideation or
plan. She has had at least 7 admissions in the previous 5 years, and she An understanding pertains to the actual disease process, and an
was force-fed on 1 occasion. All therapy has so far failed. Although she appreciation relates to how the course of the disease impacts the specific
sometimes feels that she would be better off dead, Miss Jones does not individual. In other words, appreciation personalizes the physical,
believe that her life is being compromised by her refusal of hydration psychological, spiritual and emotional impact of the illness on the
and nutrition. She emphatically refuses to be force-fed, claiming that affected individual. In this instance, it appears that the patient fails to
it had previously been a very degrading experience and violated her meet this criterion. It is important to note that the failure to meet the
basic values and beliefs. There is disagreement amongst the team (which criteria for capacity is not based on the actual decision, but partly on the
includes 2 physicians) concerning how to care for Miss Jones in this lack of congruence between her beliefs and values and her choices. (It
situation. Miss Jones’ closest relative, her father, feels that he is not in is important to remember that irrationality, by itself, does not constitute
a position to override his daughter’s wishes. What ought to be done? incompetency.) It’s important that the team arrives at decision with
Why? regard to the patient’s competency.
It seems as if the team needs to arrive at decision promptly given
Stage One: Information Gathering the patient’s rapidly deteriorating condition.
The main stakeholder is the patient. A particular course of action,
albeit not to intervene to force-feed, could lead to her demise. Other Stage Two: Separation of Legal, Clinical & Ethical Facets
stakeholders include her significant others, in particular, her father. This dilemma comprises a predominantly ethical component because
Her father is already involved in decisions relating to her care, and it the most pressing issue relates to a value conflict (the right to autonomy
is important to ensure that either there is a Form 14 signed authorizing versus the duty to beneficence). The duty to rescue stems from this moral
such involvement or that the patient has been determined to be mentally dimension.
incompetent and her father is the duly elected substitute decision maker.
Should the patient have an advance directive or living will, then this Stage Three: Pertinent Ethical Duties & Obligations
should be respected. (Having said this, it is important to remember that
it is not in keeping with acceptable standards of health care practice to Autonomy: The patient neither wishes to eat or drink nor to be force-
accept or respect suicide notes as legitimate living wills. If the patient fed. The patient’s ability to make autonomous decisions is questionable.
does not have a terminal illness, the legitimacy of her request not to be The patient does not have an advance care directive or living will.
hydrated or force-fed is questionable.) Beneficence and non-maleficence: Very serious harms will befall
Other stakeholders are staff members and the hospital. Staff the patient if her current wishes are respected – she will die. This could be
members have their personal and professional integrity to maintain and viewed as medical negligence. Other stakeholders (family and staff) may
the decisions that they make should be such that they could live with and feel guilty for not intervening to rescue her. On a burden/benefit analysis:
should reflect acceptable professional practice. Additionally, staff and Force-feeding could result in the patient feeling embittered toward family
the hospital could be held liable for failure to provide due care including and staff for overriding her wishes, and this might negatively impact her

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Making Ethical Choices Making Ethical Choices

personal and therapeutic relationships. health care.

There is considerable discomfort associated with force-feeding,
and this may include complications from naso-gastric feeding and more Stage Six: Resolution Strategy with Preferential Scale
invasive procedures such as a gastrostomy. It might also include physical The treatment team could decide not to force-feed the patient, but
and chemical restraints to keep the patient from pulling out her feeding this would inevitably lead to her demise. The fact that she lacks capacity
and hydration tubes. Anticipated benefits include saving the patient’s life to consent to, or refuse, treatment is extremely important, because it then
and restoring her ability to make autonomous choices. Not intervening becomes incumbent on the treatment team to rescue her from preventable
or delayed intervention would, on the other hand, result in the patient’s suffering and death. It is possible to argue that her elderly father needs
death, which, despite ambivalence about life, the patient does not wish. to understand and appreciate the consequences of all viable options. The
Justice: Despite the chronicity of her disorder and the need for patient’s father needs all pertinent information relating to his daughter’s
ongoing care even though she sometimes refuses this, the patient is condition so that he would make an informed decision.
entitled to a ‘fair’ share of health care resources. The general rule of The treatment team would need to also consider the father’s
thumb is what would another reasonable interdisciplinary treatment emotional attachment to his daughter, and every effort should be made to
team most likely provide under similar circumstances. foster an atmosphere that would promote the patient’s best interest (and
prior expressed capable wishes if known), the team’s primary obligation.
Stage Four: Identification of Conflict The treating team should attempt to negotiate an acceptable approach
There are numerous problems but the primary one relates to whether with the patient and her father. Seeking ethics and legal counsels would
or not the patient should be force-fed. This is a conflict between the be prudent. Should the father refuse to give consent for force-feeding, the
principles of beneficence and respect for autonomy. treatment team should seek urgent counsel with the Consent & Capacity
Board. The Mental Health Act allows for alternative proxy, such as
another family member or a Public Guardian & Trustee, in situations
Stage Five: Critical Analysis & Viable Alternatives where the substitute decision-maker is viewed as not acting in accordance
There is a legal duty to rescue patients who are in imminent and with legislative requirements for substitute decision-making.
serious danger. If, however, this patient were terminally ill, then
It is crucial to remind substitute decision makers that what is
perhaps it would be morally permissible to forego force-feeding, as
essentially required of them is decisions based on the patient’s values,
it would be undesirable to prolong death with extravagant medical
beliefs and preferences rather than what they themselves might choose
intervention.66 Palliative care would be the most appropriate under such
under the circumstances.
circumstances.
It is, therefore, extremely important to determine whether in fact Stage Seven: Action Implementation
the patient is terminally ill, for example, suffering from heart failure
or multiple organ failure due to severe and advanced anorexia. Expert Despite the patient’s refusal to consent to nutrition and hydration,
consultation in this regard becomes extremely important. the decision and rationales should be explained to the patient, addressing
all questions and concerns that the patient might have. Every attempt
The wishes of adult patients who are incontrovertibly competent must be made to engage and collaborate with the patient and her father.
to consent to, and refuse, treatments should under most circumstances Ideally with the father’s consent, the patient should be transferred to an
be respected. Patients for whom medical intervention will most likely appropriate unit for forced-feeding, where it will be administered with
not benefit any longer, thus not fulfilling one of the primary goals of the least possible intrusion, with compassion, and only for as long as
health care, would perhaps be better cared for through palliation. There it is necessary (before she regains capacity). When the patient regains
is no obligation on health care professionals to provide medically futile capacity to make competent care decisions, then these ought to be
treatments. Futility in this context means that the intervention is highly respected.
unlikely to achieve the ends that it is intended to or, indeed, the goals of

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Making Ethical Choices Making Ethical Choices

Stage Eight: Evaluation of Effectiveness Endnotes

It is crucial to determine how effective the medical intervention
(force-feeding) has been. The central goals are to rescue the patient from Introduction
a life-threatening medical crisis, at least until her capacity has been re- 1 Howard Brody, Ethical Decisions in Medicine (Boston: Little Brown
established. Therefore, it is important to assess for medical stability and and Company, 1981) pp. 5-11.
competency to consent to, or refuse, treatments. 2 Sheila Bunting and Adele Webb, “An Ethical Model for Decision-
Making,” Nurse Practitioner, 1988:13(12) pp. 30-34.
Stage Nine: Preventative Strategies 3 J. Thompson and H. Thompson, Bioethical Decision-making for
Nurses (Norwalk, Ct.: Appleton-Century-Croft, 1985).
Unfortunately, such complex medico-ethical situations will 4 Mary Murphy and James Murphy, “Making Ethical Decisions –
occasionally occur in health care, given the nature of severe and Systematically,” Nursing, May 1976, pp. 13-14.
persistent illness and the morally diverse environment wherein health 5 Mila Aroskar, “Anatomy of an Ethical Dilemma: The Theory,”
care practice occurs. However, once these situations occur, it is of American Journal of Nursing, April 1980, pp. 658-660.
paramount importance to act promptly, using a clear and methodological 6 Mila Aroskar, “Anatomy of an Ethical Dilemma: The Practice,”
decision-making process, in order to arrive at morally justifiable choices. American Journal of Nursing. April 1980, pp. 661-663.
Advance Care Directives can be extremely useful in these situations and 7 L. Curtin and M. Flaherty, Nursing Ethics: Theories and Pragmatics.
its use should be strongly encouraged when patients possess the capacity (Virginia, Maryland: Prentice-Hall Int., 1992) pp. 57-63.
to undertake advance care planning. 8 R. Grundstein-Amado, “An Integrative Model Of Clinical-Ethical
The use of the decision-making model is invaluable in critically Decision-making,” Theoretical Medicine, 1991:12, pp. 157-170.
working through the dilemma, ensuring that all pertinent interests are 9 L. McCullough, “A Primer on Bioethics,” Seminar given to American
duly considered and weighed and all biases and prejudices are identified College of Physician Executives in 1994. Unpublished. pp. 1-35.
and kept in check. 10 A. Jonsen, M. Siegler, and W. Winslade, Clinical Ethics (New York:
McGraw-Hill, Inc., 1992).
11 College of Nurses of Ontario, Guidelines for Professional Behaviour
(Toronto: College of Nurses of Ontario, 1995) pp. 1-17.
12 Paula Chidwick, “Approaches To Clinical Ethical Decision-Making:
Ethical Theory, Casuistry and Consultation” (Unpublished PhD
thesis, 1994) p. 116.

Ethics
13 Raanan Gillon, Philosophical Medical Ethics (Chichester: John
Wiley and Sons for The British Medical Journal, 1986) p. 2.
14 There are tomes of information concerning the philosophy of religion
and spirituality. As an example, please see M. Peterson, W. Hasker,
B. Reichenbach, and D. Basinger, Reason & Religious Belief (New
York: Oxford University Press, 1991).

Ethical Approaches
15 Other common ethical theories include natural law and divine
command theory. For a detailed discussion of these legitimate sources
of morality, please refer to T. Beauchamp and J. Childress, Principles
of Biomedical Ethics (New York: Oxford University Press, 1994);

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Making Ethical Choices Making Ethical Choices

John Arras and Nancy Rhoden, Ethical Issues in Modern Medicine in particular, should also be readily accessible to the comprehension
(California: Mayfield Publishing Co., 1989); Thomas Mappes and and appreciation of most members of society. Health care institutions
Jane Zembaty, Biomedical Ethics (New York: McGraw-Hill Inc., are a vital part of our social (and political) structure, and there is an
1991); Tom Beauchamp and LeRoy Walters, Contemporary Issues inherent accountability and responsibility to the general public –
In Bioethics (California: Wadsworth Publishing Co., 1982). past, current, and potential patients. In the ethical decision-making
16 J. S. Mill, Utilitarianism in J.S. Mill and J. Bentham, Utilitarianism process, there are active participants (for example, health care
and Other Essays, ed. A. Ryan (Harmondsworth: Penguin, 1987). professionals, the patient and his significant others) and there are
17 I. Kant, Groundwork of the metphysics of morals (London: Harper passive participants (for example, other citizens, past and potential
and Roaw, 1964). Translated and analysed by H.J. Paton. patients, as well as other health care professionals). This is a ‘cyclic-
18 Casuistry is not necessarily exclusive of the application of moral type’ process. On the one hand, public opinion and outcry bear a
principles, and Paul Ramsey, an eminent Anglican writer on medical tremendous influence on the events in an institution, sometimes in
ethics, advocates a very rigorous form of casuistry in which he a current case, but usually in future deliberations (because decisive
combines diligent attention to detail with an equally conscientious actions were already implemented). On the other hand, citizens gain
attention to theological principles. For detailed discussions on greater insights into the events that occur in health care institutions,
the casuistry approach, please refer to Paul Ramsey, The Patient and these often influence their expectations, for example, they would
As Person (Mass.: Yale University Press, 1975); Albert Jonsen, reconsider the possibility of having easy access to a triple valve
Mark Siegler, and William Winslade, Clinical Ethics (New York: cardiac operation if it were clear that this was not readily available
McGraw-Hill, Inc., 1992); Albert Jonsen and S. Toulmin, The Abuse to everyone who was suffering from cardiac valve difficulties.
of Casuistry (Berkley: University of California Press, 1988).
19 This approach promotes a multidisciplinary team consultation Ethical Decisions
perspective. 24 I. A. Thompson, K. M. Melia and K. M. Boyd, Nursing Ethics
20 Meta-ethics is basically the inquiry about the meaning of ethical (Edinburgh: Churchill Livingstone, 1988) p. 3.
terms and concepts (for example, ‘mental competency’, ‘rationality’, 25 A. V. Campbell, Moral Dilemmas in Medicine, (Edinburgh: Churchill
and ‘personhood’) as well as the relation of ‘facts’ to values. Livingstone, 1975) pp. 2-3.
21 Descriptive ethics is basically the inquiry into the moral perspectives 26 M. A. Aroskar, “Anatomy of an Ethical Dilemma: The Theory,”
held by various individuals and diverse cultures, as well as whether American Journal of Nursing, April 1980, p. 658.
any of these views are universally held. 27 Ibid, p. 658.

Defining Ethical Dilemmas Ethical Consensus

22 It is possible to argue that circumstances objectively change cases. 28 By the very nature of moral decision-making, the individual should
Consider, for example, Renford Bambrough’s argument that “To be an autonomous participant, and the deliberated decision ought to
suggest that there is a right answer to a moral problem is at once to be void of coercion and manipulation.
be accused of or accredited with a belief in moral absolutes. But it is 29 To illustrate: moral decision-making in a cultural and moral
no more necessary to believe in moral absolutes in order to believe pluralistic modern health care institution (with a multidisciplinary
in moral objectivity than it is to believe in the existence of absolute team approach) might be contrasted with the relative ease with
space or absolute time in order to believe in the objectivity of which ‘unanimity’ might be achieved in a local rural church.
temporal and spatial relations and of moral judgements about them”. 30 One example is a person with schizophrenia who refuses
Renford Bambrough, Moral Skepticism and Moral Knowledge (New antipsychotic medication and presents an imminent danger to himself
Jersey: Humanities Press, 1979) p. 33. and/or others; and/or demonstrates a grave lack of competence to
23 Moral decisions made in a health care institution should be reflective care for himself/herself; and whose mental condition would most
of the general norms and values of a particular society, and it is likely be significantly improved by the proposed treatment. Before
possible to argue that the decision-making process and the resolution, any treatment commences, the patient has ready access to a Review

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Making Ethical Choices Making Ethical Choices

Board (which consists of a duly elected psychiatrist, a lay-person, justifiable reasons for their viability and preference, that the patient
and a lawyer) which reviews the entire case and, in a quasi-judicial can best appreciate the situation in its entirety.
hearing, weighs the arguments presented by both parties (that is, There are several patient-physician relationship models, and the
the attending psychiatrist, primary nurse, and social worker, as well extent of the involvement of the patient in the ethical decision-making
as the patient and/or his/her alternative decision-maker, and his process would depend on which of these models one endorses. Robert
significant others). If so decided, treatment is administered to the M. Veatch offers several models: First, the ‘engineering model’ – the
‘involuntary’ patient for a specified period following which another clinician, as a scientist, operates in what he generally perceives to
review is conducted. Furthermore, the patient and/or his/her proxy, be a purely empirical world, and values are marginalized or ignored
as indeed, the attending psychiatrist, can appeal the decision made altogether. The clinician is “a plumber without any moral integrity.”
by the Review Board to a District Court. Second, the ‘priestly model’ – the physician is viewed as a priest.
31 Kurt Bayertz, “Introduction: Moral Consensus as a Social and The primary criticism, according to Veatch, is “one of generalization
Philosophical Problem,” The Concept of Moral Consensus, ed. Kurt of expertise: transferring of expertise in the technical aspects of a
Bayertz (Netherlands: Kluwer Academic Publishers, 1994) p. 13. subject to expertise in moral advice.” As a result, the clinician’s
32 Ibid., p. 13. moral authority dominates the patient and the patient’s freedom
and dignity are severely restricted. Third, the ‘collegial model’ –
The Team this attempts to balance the two former models, and the physician
33 Patients are no longer submissive and passive agents who allow is viewed as the patient’s “pal”. There is shared dignity and trust
doctors to decide, by themselves, what is in their (the patients’) between both parties. However, Veatch points out that “ethnic, class,
best interest. The shifting paradigm in health care delivery is taking economic, and value differences make the assumption of common
us toward increased ‘health care consumerism’, that is, toward interest which is necessary for the collegial model to function a mere
increased mutual consultation and collaboration between the patient pipe-dream.” This model is, therefore, unrealistic and impractical.
(the consumer) and health care providers. Today, with the more Lastly, the ‘contractual model’ – herein lie the virtues of truth-telling,
assertive and better informed patient who now seeks an active part in freedom, dignity, confidentiality, and justice. Duties and obligations
determining what happens to him/her, and because it is he/she who are monitored and sanctioned by social systems. According to
has most at stake in the proceedings of ethical decision-making, it is Veatch, “In the contractual model, then, there is a real sharing of
possible to argue that he/she has a right to be included in the process decision-making in a way that there is a realistic assurance that
by reason of respect for patient autonomy. Honouring of beneficence both patient and physician will retain their moral integrity.” This
is also enhanced through the active involvement of the patient, handbook adopts the contractual model as being most appropriate
because he/she or his/her proxy has direct access to the proceedings for the ethical decision-making process (as for the entire patient-
and his/her input – feelings, values, and opinions – would receive clinician relationship) because of its emphasis on mutual respect and
due consideration. It should be remembered that opinions and values consideration of each other’s values and integrity. Please refer to
might very well be modified during rational discourse, and this can Robert M. Veatch, “Models for Ethical Medicine in a Revolutionary
be very beneficial to all concerned. In other words, simply because Age,” Ethical Issues in Modern Medicine, ed. J. D. Arras and N. K.
the patient is a patient (and it is generally assumed that he/she may Rhoden (California: Mayfield Publishing Press, 1989) pp. 52-55.
be suffering, physically and/or emotionally), one should not hasten 34 It is important to note that patient confidentiality is an exceedingly
to exclude him/her from actively participating in the process (unless important consideration, and the inclusion of family members or
it is his/her expressed desire to be excluded), under the pretext that significant others must only follow the explicit permission to do so
he/she would perhaps find the proceedings unbearably stressful – from the patient. Of course there are exceptions, for example, when
this would be a paternalistic attitude. A most important feature of attempting to manage an emergency situation or when it is evident
the procedure is the democratic, impartial and benevolent nature that the patient is unable to himself/herself express this desire – the
of the process itself. It is in such an atmosphere wherein diverse use of caution and professional integrity and sensitivity, as well as
alternatives in choices and perspectives are presented with rationally the involvement of duly appointed proxies are clearly warranted.

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Making Ethical Choices Making Ethical Choices

For detailed criteria of what constitutes a duly elected proxy, please ‘informed consent’. Once the clinician-patient relationship has been
refer to T. Beauchamp and J. Childress, Principles of Biomedical established, the clinician generally provides the patient with a set of
Ethics (New York: Oxford University Press, 1994). treatment alternatives including his professional preference, and the
35 A. Jameton, Nursing Practice: The Ethical Issues (New Jersey: patient then not only has the right to choose from the alternatives
Prentice-Hall Inc., 1984). Also, please refer to Judith Wilkinson, offered, but also to refuse any treatment.
“Moral Distress in Nursing Practice: Experience and Effect,” 43 According to the Mental Health Act, a patient can be held against
Nursing Forum, 1987/1988:1. his/her will in a safe institution if he/she were considered an
imminent danger to himself/herself and/or to others. Please refer to
Effective Team Deliberation The Ministry of Health of Ontario, Rights and Responsibilities: A
36 A ‘prima donna’ may be differentiated from a legitimate leader Guide to the Mental Health Act, p. 3.
by reason of the fact that he/she tends to monopolize the group, 44 Joseph King, The Law of Medical Malpractice (Minnesota: West
generally influencing the proceedings by his/her personal agendas Publishing Co., 1977) pp. 8-35.
and prejudices, and often creating an atmosphere replete with choas, 45 A. Meagher, P. Marr, and R. Meagher, Doctors and Hospitals: Legal
disrespect, and resentment. Duties (Vancouver: Butterworths Canada Ltd., 1991).
37 Bruce Ackerman, “Why Dialogue,” The Journal of Philosophy,
1989:LXXXVI, p.15. Moral Reasoning
38 For example: from a pragmatic perspective, in discussing a pressing 46 For a more detailed reading of moral maturity please see W. Hughes,
case of whether or not a pregnant 13-year old rape victim ought Critical Thinking (Peterborough, Ontario: Broadview Press, 1992).
to be granted an abortion, it is perhaps much more prudent and
productive to consider the physical and psychological effects of The Law
compelling the young girl to carry the unwanted foetus to term (as 47 Even within this century we have seen the lawful and systematic
well as the enormous adverse consequences of having an unwanted discrimination of women and minorities (racial and cultural groups
child), rather than to engage in prolonged and usually unfruitful as well as mentally challenged and disordered individuals). Consider,
debates regarding meta-ethical concepts such as ‘sanctity of life’ for example, the indiscriminate sterilization of children considered
(unless this becomes the focus of an argument presented). mentally retarded until only a couple of decades ago.
39 The patient’s values are relatively more important to other values 48 For a more detailed examination of the relationship between Biothics
in the specific discussion because he/she has the most at stake. It is and the law, please refer to D. Roy, J. Williams and B. Dickens,
not because his/her values are ‘superior’ in any general or absolute Bioethics in Canada (Scarborough, Ontario: Prentice-Hall Canada
sense. Inc., 1994).
49 A. Meagher, P. Marr, and R. Meagher, Doctors and Hospitals: Legal
Pitfalls to Avoid Duties (Vancouver: Butterworths Canada Ltd., 1991).
40 L. McCullough, Primer on Bioethics (Unpublished, 1994) p. 4. 50 For a more detailed account of liability risks in psychiatry, please
see A Comprehensive Guide to Malpractice: Risk Management
Fallacies in Psychiatry, ed. Frederic Flach (New York: Hatherleigh Press,
41 For a more detailed account of fallacies, please see Logic and 1998).
Rational Thought (St Paul, USA: West Publishing Company,
1992). Professional Code of Ethics
51 According to Sieghart (1982), “Professional codes, if they are to
Personal Values be worth anything, cannot merely confine themselves to asserting
42 Health care professionals, by reason of their formal education and that there is a problem and leaving it at that – let alone leaving it
(professional) experience, have been socially sanctioned/authorized to the individual members of the profession to solve the complex
to diagnose and treat as deemed necessary within the competencies as best as they can, consulting their unguided consciences and
of their professions and with the adult mentally competent patient’s perhaps a few respected colleagues. At the least, such a code must
64 65
Making Ethical Choices Making Ethical Choices

say something about how to approach this kind of problem.” P. Health Care Professional Act in Ontario), vulnerable adults in
Sieghart, “Professional Ethics – for whose benefit?” Journal of danger of serious harms (under the moral and legal duty to rescue
Medical Ethics, 1982:8, pp. 25-32. and care).
52 An examination of German psychiatrists’ “code of ethics” during 58 For an interesting examination of arguments relating to the role of
the Third Reich and their active participation in the elimination of employees as ‘loyal’ agents, please see Business Ethics in Canada,
innocent and vulnerable people bear witness to atrocities conducted ed. D. Poff and W. Waluchow (Scarborough, Ontario: Prentice-Hall
by “trusted” professionals who had a fiduciary relationship with Canada Inc., 1991).
them. See, for example, L. Lapon, Mass Murderers in white coats.
Psychiatric genocide in Nazi Germany and the United States The Virtues (compliment Ethical Principles)
(Springfield, Il.: Psychiatric Genocide Research Institute, 1986). 59 Aristotle, Nicomachean Ethics, transl. W.D. Ross, revised by J.L
Also, R. Lifton, The Nazi Doctors. Medical killing and the psychology Ackrill and J.O. Urmson, (Oxford: Oxford University Press, 1980).
of genocide (New York: Basic Books, 1986). For an examination 60 Aristotle, EN, II, p. 6.
of atrocities conducted by qualified Soviet psychiatrists, please see
Ethical Decision-Making Model
M. Lader, Psychiatry on trial. (Harmondsworth: Penguin, 1977). Of
61 David Hume, An Enquiry Concerning the Principles of Morals, ed.
course, North Americans also have a legacy of detrimental abuse and
Eric Steinberg and J. B. Schneewind (Indiana: Hackett Publishing
oppression of severely mentally ill patients, for example, through
Company Inc., 1983) pp. I, 15.
medical research conducted at McGill University a few decades
62 These are some of the ethical and legal requirements for mandatory
ago.
intervention. Please also refer to Endnote 26.
Institution’s Mission, Values, Policies & Practices 63 Alastair Campbell, Grant Gillett, and Gareth Jones, Practical
53 Aristotle, Nicomachean Ethics, transl. W. D. Ross, revised by J.L Medical Ethics (Aukland: Oxford University Press, 1992) p. 14.
Ackrill and J.O. Urmson, (Oxford: Oxford University Press, 1980). 64 H. Brody, Ethical Decisions in Medicine (Boston: Little, Brown and
54 See, for example, H. Smith and A. Carroll, “Organizational Ethics: Company, 1981) p. 7.
A stacked Deck,” Journal of Busniess Ethics, 1984:3(2), pp. 95- 65 Even if it does not involve a predominantly clinical element, it is
100. important to remember that one would still need to incorporate
55 For a more detailed examination of this concept please see L. Irving, clinical considerations in the deliberation.
“Groupthink” Psychology Today. 1971 (in Staw), pp. 407-410. See
Case Study
also C. Madden, “Forces Which Influence Ethical Behaviour,” The
66 Schneiderman, L., Faber-Langendoen, K., Jecker, N. “Beyond
Ethics of Corporate Conduct, ed. Clarence Walton (New Jersey:
futility to an ethic of care,” American Journal of Medicine, 1994:96,
Prentice-Hall, Englewood Cliffs, 1977).
pp. 110-114.
Ethical Principles & Guidelines
56 Simon, R. Psychiatry and Law for Clinicians (Washington, DC:
American Psychiatric Press, 1998).
57 In this regard, it is important to note that the primary justification for
breaching patients’ confidentiality is serious risk of harm to oneself
and/or another (others). These situations include communicable
diseases (the Ontario Health Protection and Promotion Act), child
abuse (Child Protection Act), driving safety (under highway traffic
legislation), flying safety (under the Federal Aeronautics Act),
dangerous patients (the Mental Health Act and the duty to warn as
derived from the Tarasoff case), sexual misconduct (The Regulated

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Making Ethical Choices Making Ethical Choices

Bibliography
Aroskar, M. A. “Anatomy of an Ethical Dilemma: The Theory.” American
Journal of Nursing. April 1980, p. 658.
Bambrough, R. Moral Skepticism and Moral Knowledge. New Jersey:
Humanities Press, 1979.
Beauchamp, T. and Childress, J. Principles of Biomedical Ethics. New
York: Oxford University Press, 1994.
Brody, H. Ethical Decisions in Medicine. Boston: Little, Brown and
Company, 1981.
Poff, D. and Waluchow, W. (eds.) Business Ethics in Canada. Scarborough,
Ontario: Prentice-Hall Canada Inc., 1991.
Campbell, A., Gillett G. and Jones, G. Practical Medical Ethics. Aukland:
Oxford University Press, 1992.
Campbell, A.V. Moral Dilemmas in Medicine. Edinburgh: Churchill
Livingstone, 1975.
Gillon, R. Philosophical Medical Ethics. Chichester: John Wiley and
Sons for The British Medical Journal, 1986.
Hume, D. An Enquiry Concerning the Principles of Morals. Ed. Eric
Steinberg and J. B. Schneewind. Indiana: Hackett Publishing
Company Inc., 1983.
Jameton, A. Nursing Practice: The Ethical Issues. New Jersey: Prentice-
Hall Inc., 1984.
King, J. The Law of Medical Malpractice. Minnesota: West Publishing
Co., 1977.
Lader, M. Psychiatry on Trial. Harmondsworth: Penguin, 1977.
Lapon, L. Mass Murderers in White Coats. Psychiatric Genocide in
Nazi Germany and the United States. Springfield, Il.: Psychiatric
Genocide Research Institute, 1986.
Lifton, R. The Nazi Doctors. Medical Killing and the Psychology of
Genocide. New York: Basic Books, 1986.
Madden, C. “Forces Which Influence Ethical Behaviour.” The Ethics of
Corporate Conduct. Ed. Clarence Walton. New Jersey: Prentice-
Hall, Englewood Cliffs, 1977.
McCullough, L. Primer on Bioethics. Unpublished, 1994.
Mill, J. S. On Liberty. Ed. A. Castell. Illinois: AHM Publishing

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Making Ethical Choices Making Ethical Choices

Corporation, 1947. Appendix 1: Canadian Medical

Peterson, M., Hasker, W., Reichenbach, B. and Basinger, D. Reason &
Religious Belief. New York: Oxford University Press, 1991.
Association Code of Ethics
Roy, D., Williams, J. and Dickens, B. Bioethics in Canada. Scarborough, General Responsibilities
Ontario: Prentice-Hall Canada Inc., 1994.
1. Consider first the well-being of the patient.
Sieghart, P. “Professional Ethics – For Whose Benefit?” Journal of
Medical Ethics. 1982:8, pp. 25-32. 2. Treat all patients with respect; do not exploit them for personal
advantage.
Smith, H. and Carroll, A. “Organizational Ethics: A Stacked Deck.”
Journal of Busniess Ethics. 1984:3(2), pp. 95-100. 3. Provide for appropriate care for your patient, including physical
comfort and spiritual and psychosocial support even when cure is
The Ministry of Health of Ontario. Rights and Responsibilities: A Guide no longer possible.
to the Mental Health Act.
4. Practise the art and science of medicine competently and without
Thompson, I. A., Melia, K. M. and Boyd, K. M. Nursing Ethics. impairment.
Edinburgh: Churchill Livingstone, 1988.
5. Engage in lifelong learning to maintain and improve your professional
Veatch, R. M. “Models for Ethical Medicine in a Revolutionary Age.” knowledge, skills and attitudes.
Ethical Issues in Modern Medicine. Ed. J. D. Arras and N. K.
Rhoden. California: Mayfield Publishing Press, 1989. 6. Recognize your limitations and the competence of others and when
indicated, recommend that additional opinions and services be
Wilkinson, J. “Moral Distress in Nursing Practice: Experience and sought.
Effect.” Nursing Forum. 1987/1988:1.
Responsibilities to the Patient
Initiating and Dissolving a Patient-Physician Relationship
7. In providing medical service, do not discriminate against any patient
on such grounds as age, gender, marital status, medical condition,
national or ethnic origin, physical or mental disability, political
affiliation, race, religion, sexual orientation, or socio-economic
status. This does not abrogate the physician’s right to refuse to
accept a patient for legitimate reasons.
8. Inform your patient when your personal morality would influence
the recommendation or practice of any medical procedure that the
patient needs or wants.
9. Provide whatever appropriate assistance you can to any person with
an urgent need for medical care.
10. Having accepted professional responsibility for a patient, continue
to provide services until they are no longer required or wanted;
until another suitable physician has assumed responsibility for the
patient; or until the patient has been given adequate notice that you
intend to terminate the relationship.

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11. Limit treatment of yourself or members of your immediate family to of confidentiality would result in a significant risk of substantial harm
minor or emergency services and only when another physician is not to others or to the patient if the patient is incompetent; in such cases,
readily available; there should be no fee for such treatment. take all reasonable steps to inform the patient that confidentiality
will be breached.
Communication, Decision-making and Consent
23. When acting on behalf of a third party, take reasonable steps to
12. Provide your patients with the information they need to make ensure that the patient understands the nature and extent of your
informed decisions about their medical care, and answer their responsibility to the third party.
questions to the best of your ability.
24. Upon a patient’s request, provide the patient or a third party with
13. Make every reasonable effort to communicate with your patients in a copy of his or her medical record, unless there is a compelling
such a way that information exchanged is understood. reason to believe that information contained in the record will result
14. Recommend only those diagnostic and therapeutic procedures in substantial harm to the patient or others.
that you consider to be beneficial to your patient or to others. If a
procedure is recommended for the benefit of others, as for example Clinical Research
in matters of public health, inform your patient of this fact and 25. Ensure that any research in which you participate is evaluated both
proceed only with explicit informed consent or where required by scientifically and ethically, is approved by a responsible committee
law. and is sufficiently planned and supervised that research subjects are
15. Respect the right of a competent patient to accept or reject any unlikely to suffer disproportionate harm.
medical care recommended. 26. Inform the potential research subject, or proxy, about the purpose of
16. Recognize the need to balance the developing competency of the study, its source of funding, the nature and relative probability of
children and the role of families in medical decision-making. harms and benefits, and the nature of your participation.

17. Respect your patient’s reasonable request for a second opinion from 27. Before proceeding with the study, obtain the informed consent of
a physician of the patient’s choice. the subject, or proxy, and advise prospective subjects that they have
the right to decline or withdraw from the study at any time, without
18. Ascertain wherever possible and recognize your patient’s wishes prejudice to their ongoing care.
about the initiation, continuation or cessation of life-sustaining
treatment. Professional Fees
19. Respect the intentions of an incompetent patient as they were 28. In determining professional fees to patients, consider both the nature
expressed (e.g., through an advance directive or proxy designation) of the service provided and the ability of the patient to pay, and be
before the patient became incompetent. prepared to discuss the fee with the patient.
20. When the intentions of an incompetent patient are unknown and
when no appropriate proxy is available, render such treatment as Responsibilities to Society
you believe to be in accordance with the patient’s values or, if these 29. Recognize that community, society and the environment are
are unknown, the patient’s best interests. important factors in the health of individual patients.
21. Be considerate of the patient’s family and significant others and 30. Accept a share of the profession’s responsibility to society in matters
cooperate with them in the patient’s interest. relating to public health, health education, environmental protection,
legislation affecting the health or well-being of the community, and
Confidentiality the need for testimony at judicial proceedings.
22. Respect the patient’s right to confidentiality except when this right 31. Recognize the responsibility of physicians to promote fair access to
conflicts with your responsibility to the law, or when the maintenance health care resources.

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32. Use health care resources prudently. Appendix II: Canadian Nurses
33. Refuse to participate in or support practices that violate basic human
rights.
Association Code of Ethics
34. Recognize a responsibility to give the generally held opinions of CLIENTS
the profession when interpreting scientific knowledge to the public; I
when presenting an opinion that is contrary to the generally held
opinion of the profession, so indicate. A nurse is obliged to treat clients with respect for their individual
needs and values.
Responsibilities to the Profession Standards
35. Recognize that the self-regulation of the profession is a privilege 1. Factors such as the client’s race, religion, ethnic origin, social status,
and that each physician has a continuing responsibility to merit this sex, age or health status may not be permitted to compromise the
privilege. nurse’s commitment to that client’s care.
36. Teach and be taught. 2. The expectations and normal life patterns of clients are acknowledged
37. Avoid impugning the reputation of colleagues for personal motives; individualized programs of nursing care are designed to accommodate
however, report to the appropriate authority any unprofessional the psychological, social, cultural and spiritual needs of clients, as
conduct by colleagues. well as their biological needs.
38. Be willing to participate in peer review of other physicians and to 3. The nurse does more than respond to the requests of clients, by
undergo review by your peers. accepting an affirmative obligation to aid clients in their expression
of needs and values within the context of health care.
39. Enter into associations only if you can maintain your professional
integrity. 4. Recognizing the client’s membership in a family and a community,
the nurse, with the client’s consent, attempts to facilitate the
40. Avoid promoting, as a member of the medical profession, any
participation of significant others in the care of the client.
service (except your own) or product for personal gain.
41. Do not keep secret from colleagues the diagnostic or therapeutic II
agents and procedures that you employ.
Based upon respect for clients and regard for their right to control
42. Collaborate with other physicians and health professionals in the their own care, nursing care should reflect respect for the right of choice
care of patients and the functioning and improvement of health held by clients.
services.
Standards
Responsibilities to Oneself 1. The competent client’s consent is an essential precondition to the
43. Seek help from colleagues and appropriately qualified professionals provision of health care. Nurses bear the primary responsibility to
for personal problems that adversely affect your service to patients, inform clients about the nursing care that is available to them.
society or the profession. 2. Consent may be signified in many different ways. Verbal permission
or knowledgeable cooperation are the usual forms in which clients
Reprinted with permission from the Canadian Medical Association. consent to nursing care. In each case, however, a valid consent
represents the free choice of the competent client to undergo that
care which is to be provided.
3. Consent properly understood is the process by which a client

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becomes an active participant in care. All clients should be aided for the purpose of teaching, research or quality assurance.
in becoming active participants in their care to the maximum extent In this case, special care must be taken to protect the client’s
that circumstances permit. Professional ethics may require of the anonymity. Whenever possible, the client should be informed
nurse actions that exceed the legal requirements of consent. For of these necessities at the onset of care.
example, although a child may be legally incompetent to consent, 3. An affirmative duty exists to institute and maintain practices that
nurses should nevertheless attempt to inform and involve the child protect client confidentiality, for example, by limiting access to
in treatment. records.
4. Force, coercion and manipulative tactics must not be employed in
the obtaining of consent. Limitations
5. Illness or other factors may compromise the client’s capacity for self- The nurse is not morally obligated to maintain confidentiality when
direction. Nurses have a continuing obligation to value autonomy the failure to disclose information will place the client or third parties in
in such clients, for example, by creatively providing them with danger. Generally, legal requirements to disclose are morally justified
opportunities for choices, within their capabilities, thereby aiding by these same criteria. In facing such a situation, the first concern of the
them to maintain or regain some degree of autonomy. nurse must be the safety of the client or the third party.
6. Whenever information is provided to a client, this must be done in a Even when the nurse is confronted with the necessity to disclose,
truthful, understandable and sensitive way. it must proceed with an confidentiality should be preserved to the maximum possible extent.
awareness of the individual client’s needs, interests and values. Both the amount of information disclosed and the number of people to
whom disclosure is made should be restricted to the minimum necessary
7. Nurses should respond freely to their client’s requests for to prevent the feared harm.
information and explanation when in possession of the knowledge
required to respond accurately. When the questions of the client
IV
require information beyond that of the nurse, the client should be
informed of that fact and referred to a more appropriate health care The nurse has an obligation to be guided by consideration for the
practitioner for a response. dignity of clients.

Standards
III
1. Nursing care should be carried out with consideration for the
The nurse is obliged to hold confidential all information regarding a
personal modesty of clients.
client learned in the health care setting.
2. A nurse’s conduct at all times should acknowledge the client as a
Standards person. For example, discussion of care in the presence of the client
1. The rights of persons to control the amount of personal information should actively involve or include that client.
that will be revealed applies with special force in the health care 3. As ways of dealing with death and the dying process change, nursing
setting. It is, broadly speaking, up to clients to determine who shall is challenged to find new ways to preserve human values, autonomy
be told of their condition, and in what detail. and dignity. In assisting the dying client, measures must be taken to
2. In describing professional confidentiality to a client, its boundaries afford as much comfort, dignity and freedom from anxiety and pain
should be revealed: as possible. Special consideration is given to the need of the client’s
family to cope with their loss.
a) Competent care requires that other members of a team of health
personnel have access to or be provided with the relevant details
V
of a client’s condition.
The nurse is obligated to provide competent care to clients.
b) In addition, discussions of the client’s care may be required
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Standards The nurse is obligated to advocate the client’s interest.

1. Nurses should engage in continuing education and in the upgrading Standards
of skills relevant to the practice setting.
1. Advocating the interests of the client includes assistance in achieving
2. In seeking or accepting employment, nurses should accurately state access to quality health care. For example, by providing information
their areas of competence as well as limitations. to clients privately or publicly, the nurse enables them to satisfy
3. Nurses who are assigned to work outside of an area of present their rights to health care.
competence should seek to do that which, under the circumstances, 2. When speaking to public issues or in court as a nurse, the public is
is in the best interests of their clients. Supervisors or others should owed the same duties of accurate and relevant information as are
be informed of the situation at the earliest possible moment so that clients within the employment setting.
protective measures can be instituted. As a temporary measure, the
safety and welfare of clients may be better served by the best efforts
VIII
of the nurse under the circumstances than by no nursing care at all.
In all professional settings, including education, research and
4. When called upon outside of an employment setting to provide
administration, the nurse retains a commitment to the welfare of clients.
emergency care, nurses fulfill their obligations by providing the best
The nurse bears an obligation to act in such a fashion as will maintain
care that circumstances, experience and education permit.
trust in nurses and nursing.
Limitations
Standards
A nurse is not ethically obliged to provide requested care when
1. Nurses accepting professional employment must ascertain that
compliance would involve a violation of her or his moral beliefs. When
conditions will permit provision of care consistent with the values
that request falls within recognized forms of health care, however, the
and standards of the Code. Prospective employers should be
client should be referred to a more appropriate health care practitioner.
informed of the provisions of the Code so that realistic and ethical
Nurses who have or are likely to encounter such situations are morally
expectations may be established at the beginning of the nurse-
obligated to seek to arrange conditions of employment so that the care of
employer relationship.
clients is not jeopardized.
2. Accurate performance appraisal is required by a concern for present
VI and future clients and is essential to the growth of nurses. Nurse
administrators and educators are morally obligated to provide timely
The nurse is obliged to represent the ethics of nursing before and accurate feedback to nurses, and their supervisors, student
colleagues and others. nurses and their teachers.
Standards 3. Administrators bear special ethical responsibilities that flow from a
1. Nurses serving on committees concerned with health care or research concern for present and future clients. The nurse administrator seeks
should see their role as including the vigorous representation of to ensure that the competencies of personnel are used efficiently.
nursing’s professional ethics. Working within available resources, the administrator seeks to
ensure the welfare of clients. When competent care is threatened due
2. Many public issues include health as a major component. to inadequate resources or for some other reason, the administrator
Involvement in civic activities may afford the nurse the opportunity acts to minimize the present danger and to prevent future harm.
to further the objectives of nursing as well as to fulfill the duties of
a citizen. 4. An essential element of nursing education is the student-client
encounter. This encounter must be conducted in accordance with
ethical nursing practices, with special attention to the dignity of
VII the client. The nurse educator is obligated to ensure that nursing
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Making Ethical Choices Making Ethical Choices

students are acquainted with and comply with the provisions of the be considered:
Code. a) The nurse is obliged to ascertain the facts of the situation in
5. Research is necessary to the development of the profession of deciding upon the appropriate course of action.
nursing. Nurses should be acquainted with advances in research, b) Institutional mechanisms for reporting incidents or risks of
so that established results may be incorporated into practice. The incompetent or unethical care should be followed.
individual nurse’s competencies and circumstances may also be
used to engage in, or to assist and encourage research designed to c) It is unethical for a nurse to participate in efforts to deceive or
enhance the health and welfare of clients. mislead clients regarding the cause of their injury.
The conduct of research must conform to ethical nursing practice. d) Relationships in the health care team should not be disrupted
The self-direction of clients takes on added importance in this context. unnecessarily. If a situation can be resolved without peril to
Further direction is provided in the Canadian Nurses Association present or future clients by direct discussion with the colleague
publication entitled, Ethical Guidelines for Nursing Research Involving suspected of providing incompetent or unethical care, that
Human Subjects. should be done.
2. The nurse who attempts to protect clients threatened by incompetent
HEALTH TEAM or unethical conduct may be placed in a difficult position. Colleagues
and professional associations are morally obliged to support nurses
IX who fulfill their ethical obligations under the Code.
Client care should represent a cooperative effort, drawing upon 3. Guidance concerning those activities that may be delegated
the expertise of nursing and other health professions. Acknowledging by nurses to assistants and other health care workers is found in
personal or professional limitations, the nurse recognizes the perspective legislation and policy statements. When functions are delegated,
and expertise of colleagues from other disciplines. the nurse should be satisfied regarding the competence of those who
will be fulfilling these functions. The nurse has a duty to provide
Standards continuing supervision in such a case.
1. The nurse participates in the assessment, planning, implementation
and evaluation of comprehensive programs of care for clients. The THE SOCIAL CONTEXT OF NURSING
scope of a nurse’s responsibility should be based upon education
and experience, as well as legal considerations of licensure or XI
registration. Conditions of employment should contribute to client care and to the
2. The nurse accepts a responsibility to work with others through professional satisfaction of nurses. Nurses are obliged to work towards
professional nurses’ associations to secure quality care for clients. securing and maintaining conditions of employment that satisfy these
connected goals.
X
Standards
The nurse, as a member of the health care team, is obliged to take
steps to ensure that the client receives competent and ethical care. 1. In the final analysis, the improvement of conditions of nursing
employment is often to the advantage of clients. Over the short term
Standards however, there is a danger that action directed toward this goal will
work to the detriment of clients. Nurses bear an ethical responsibility
1. The first consideration of the nurse who suspects incompetence or
to present as well as future clients and so the following principles
unethical conduct should be the welfare of present clients or potential
should be noted:
harm to future clients. Subject to that principle, the following should
a) The safety of clients should be the first concern in planning and
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Making Ethical Choices Making Ethical Choices

implementing any job action. and continuing basis and be prepared to provide assistance to
b) Individuals and groups of nurses participating in job actions those concerned with its implementation.
share this ethical commitment to the safety of clients. However, b) Education in the ethical aspects of nursing should be available
their responsibilities may lead them to express this commitment to nurses throughout their careers. Nurses’ associations should
in different, but equally appropriate ways. actively support or develop structures designed towards this
c) Clients whose safety requires ongoing or emergency nursing end.
care are entitled to have those needs satisfied throughout the
duration of any job action. Members of the public are entitled Reprinted with permission from the Canadian Nurses Association.
to know of the steps that have been taken to ensure the safety of
clients.
d) Individuals and groups of nurses participating in job actions
have a duty of coordination and communication to take steps
reasonably designed to ensure the safety of clients.

RESPONSIBILITIES OF THE PROFESSION

XII
Professional nurses’ organizations recognize a responsibility to
clarify, secure and sustain ethical nursing conduct. The fulfillment of
these tasks requires that professional organizations remain responsive to
the rights, needs and legitimate interests of clients and nurses.

Standards
1. Sustained communication and cooperation between the Canadian
Nurses Association, provincial associations and other organizations
of nurses, is an essential step towards securing ethical nursing
conduct.
2. Professional nurses’ associations must at all times accept
responsibility for assuring quality care for clients.
3. Professional nurses’ associations have a role in representing nursing
interests and perspectives before non-nursing bodies, including
legislatures, employers, the professional organizations of other
health disciplines and the public media of communication.
4. Professional nurses’ associations should provide and encourage
organizational structures that facilitate ethical nursing conduct.
a) Changing circumstances may call for reconsideration and
adaptation of this Code. Supplementation of the code may be
necessary in order to address special situations. Professional
associations should consider the ethics of nursing on a regular
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Homewood and Guelph, Ontario
The Homewood Health Centre sits on the crest of rolling grounds
that meets the Speed River in a delicate intersection of nature’s best. Its
porticos reflect the history the Homewood embodies.
Founded 115 years ago, Homewood is one representative of how
public enterprise and public medicare can work together. Homewood
is privately owned, but provides a public service, treating people with
mental, behavioural and emotional disorders with a mix of modern
science and spiritual safety.
Homewood’s legacy has been penned by the dedication of pioneers
like Stephen Lett, its first superintendent, who projected a holistic vision
and out-comes based care well ahead of his time. The progression
continues.
Homewood today is an internationally known specialist in addiction
medicine, trauma care and treatment of depression, eating disorders and
other forms of psychiatric and emotional illness.
Ken Murray and Bill Hamilton lead the Homewood Corporation,
Mr. Murray as Chairman, and Mr. Hamilton as President. Both hold
strong beliefs in the parallel courses of clinical and community service
that Homewood has come to represent.
The Homewood Corporation is the holding company for the Health
Centre, the Homewood Behavioural Corporation and Orangewood
Properties Ltd., a property management and retirement home investment
company. Two million shares of the Homewood Corporation are traded
publicly and distributed widely.
Guelph, Ontario, is Homewood’s hometown. A city with a population
of 84,000, a strong manufacturing base, a professional and university
community, and a well-run local economy, Guelph represents a classic
blend of aesthetics, history and planned growth. It is a smaller Canadian
city nestled between bigger communities to the west and Canada’s
biggest metropolis, Toronto, an hour to the east.
 “Making Ethical Choices is a ‘must read’ for clinicians and
administrators. Our professional training has often missed translating into
sound, understandable terms, definitions and concepts related to ethics.
Nor are professional schools always able to offer necessary, practical
tools to assist the learning practitioner through perplexing choices and
dilemmas. Fortunately, through the systematic utilization of a logical
decision-making model, this handbook serves to educate and guide the
reader to analyze the situation at hand; review possible choices and
strategies; and seek collaborative, responsible and ethical decisions.”

Jill Herne, RN, CPMHN(C), BA, MS, CHE, Director of Patient Care
and Chief Nursing Officer, Homewood Health Centre.

“There is a very pressing need for lucid ethical direction in our

complex health care system with diverse values and interests. This
handbook provides a clear outline of philosophical principles and a
logical and practical ethical decision-making process as they pertain
to health care delivery. It is a well-organized overview of the basis for
ethical decision-making, and will be an invaluable guide to health care
professionals and administrators in the identification and resolution of
ethical dilemmas.”

Reid Finlayson, MD, FRCP(C), FAPA, Clinical Associate Professor of

Psychiatry, McMaster University.
 Regional Centre for Excellence in Ethics
Homewood Health Centre Inc.

www.homewood.org
www.ethika.ca

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