Ethical Reasoning

Original Editor - Andrea Sturm

Top Contributors - Wendy Walker, Rachael Lowe, Kim Jackson, Amanda Ager, Jess Bell and Robin Tacchetti  

Introduction

The ability to effectively address ethical dilemmas is an essential component of health care. The emphasis in ethical reasoning is on a sensible progression from the facts of the situation to a morally sound decision.

An ethics “workup” (this one or a similar version) may be used by a variety of health care professionals at both the organizational and individual clinical level. Health executives, physicians, nurses, physical therapists, and other health professionals use similar techniques to assess ethical dilemmas with the goal of gaining a shared sense of what is morally acceptable. With some adjustments, it may also be used by lay-persons.

The Ethics Workup

Using the five principal steps of the ethics workup, health professionals holding a variety of philosophical and religious positions regarding ethics can share a basic framework for thinking about and discussing morally troubling cases.

What are the Facts

It is vitally important to clarify the facts of any situation in order to anchor the decision. These facts relate to the organizational, medical, and social circumstances of the case. For example, at the bedside both an estimate of prognosis and an understanding of the patient's wishes are relevant to an ethical decision about what is in the patient’s best interest.

Resource allocation may be ethically relevant at the organizational level, but should provide a subsidiary influence at the bedside.

5 Step Evaluation

Answering the following questions will establish the facts to consider:

1. Who?
2. What?
3. Where?
4. When?
5. Why?

1. Who?

Establish the Persons involved and/or affected.

Remember, this may include family members of the patient, for instance.

2. What?

Consider:

• Diagnosis, prognosis, therapeutic options
• Personal preferences, beliefs, values
• Resources available
• Organizational mission and policy

3. Where?

Medical setting

4. When?

Chronology of events, time constraints

5. Why?

Patient’s goals of care and treatment

Communication

Clear and effective communication about the facts is crucial. Physical therapists may be instrumental in ensuring that the patient/family and other non-medical health professionals understand the medical facts while also making sure the health care team understands pertinent non-medical information about the patient and family. Administrators may be concerned for the welfare of the organization and those it serves as well as that of an individual patient.

What is the Ethical Concern?

Identify the specific ethical issue in the case, and there may be more than one. Ethical claims may be competing, such as the welfare of one patient versus that of many when considering resource allocation. The issue may not be ethical at all, but rather a legal issue, a placement issue, or simple miscommunication about the clinical facts.

Some common ethical concerns in the clinical setting include:

• The patient’s right to refuse or demand treatment
• Questions of futility and withholding or withdrawing treatment
• Appropriate surrogacy and substituted judgment
• Organizational limitations of services
• Policies and practices regarding privacy and confidentiality