Identifying and Analysing an Ethical Issue

Original Editor - Andrea Sturm

Top Contributors - George Prudden, Kim Jackson and Jess Bell  

Introduction

When getting aware of ethical issues you can follow a stepwise approach in your decision-making process:

• Recognize there is an issue
• Identify the problem and who is involved
• Consider the relevant facts, laws and principles
• Analyze and determine possible courses of action
• Implement the solution
• Evaluate and follow up

You can adopt any further ethical decision-making model which meets your professional needs and seems to be useful. Ask yourself within such a structured process:

• What ​should we do? (What options are good or right in this context?)
• Why ​should we do it? (Exploring the values and reasons that support each option.)
• How ​should we do it? (What plan of action best aligns with these values and reasons?)
• Who ​should do it? (Who is responsible for making the final decision and enact and

communicating it?

An ethical dilemma​ means two morally correct courses of ethics that cannot both be followed. There is a conflict between values or principles. The dilemma is that you would be doing something right and wrong at the same time, and by taking one right course you will negate the other right course.

The Ethical Decision-Making Process

To identify an issue and to structure a decision-making-process an useful framework could be the ISSUES-Concept from McMaster University, Hamilton, Canada. This applies to intra and interpersonal dilemmas, interprofessional issues and also to ethical conflicts on intra and inter-organisational levels: Values permeate everything we do in a healthcare setting and sometimes these values come into conflict; when they do, it is imperative to recognize that one is experiencing an ethical dilemma. Ethical conflicts or dilemmas are usually best resolved through direct engagement with the parties involved. Often there will not be an answer that pleases everyone and so it is our responsibility to ensure that our processes for decision-making are fair and legitimate. This tool is designed to help you think through difficult decisions—when ethics is a factor—and develop justifiable reasons for your choices in a rigorous, transparent and fair manner.

This process is captured in the acronym ISSUES

• I​dentify issue and decision-making process
• S​tudy the facts
• S​elect reasonable options
• U​nderstand values & duties
• E​valuate & justify options
• S​ustain and review the plan

It may be useful to imagine that rigorous ethical decision-making is like building a house. When we encounter ethical dilemmas our first instinct may be to find a quick fix; however our desire for resolution may cause us to misidentify the key issues or overlook important facts, values or stakeholder voices. Ethical decision-making starts with a strong foundation, based on a clear understanding of the nature of the problem and all relevant facts and perspectives, before deciding on options, weighing those options, and making the decision. See figure 3 on page 11

Guidelines for Using the Ethical Framework With Groups

Creating a forum where stakeholders have the opportunity to engage in a collaborative discussion about a particular dilemma or situation in an open and non-threatening environment is often the most efficient way to address an ethical issue.

• It is important to define at the outset of a meeting certain aspects of the process, to increase transparency, participation and satisfaction, including:
  • ground rules (i.e. everyone gets to speak uninterrupted, confidentiality of discussion, respectful interactions, etc.)
  • roles for the meeting (i.e. chair, time-keeper, recorder)
  • objectives and outcomes (i.e. the generation and analysis of reasonable options; documentation and communication plan for the decision)
  • the decision-making process (i.e. how stakeholder feedback will be used and who is ultimately responsible for making the decision)
• The appropriate worksheet (Organisational or Clinical) may be distributed to all participants to help keep the process on track. It should be worked through one section at a time, recognising that ethical decision-making is not always linear. You may have to go back and revisit earlier steps in the process as additional questions arise or facts emerge.
• Keep a copy of this toolkit handy, to provide a quick reference for key terms and concepts.
• At the end of the meeting, summarize each section of the worksheet briefly. Define a clear plan for documenting and communicating any decisions made, and assign specific individuals to accomplish next steps. As required, a follow-up meeting should be scheduled to review outcomes and address systems issues identified.

Organisational Ethics ISSUES

Process Tips:

• Identify​ the Ethical Issue and Decision-making Process:
  • Engage in reflective practice and consider your "gut reaction" to the situation: What preconceptions and judgements might you bring to the situation? What are your loyalties and intuitions? Where do these come from?
  • State the conflict or dilemma as you currently see it: Try to articulate the issue in one sentence. If you can’t, it may be better to break the problem down into two questions or issues and tackle them one at a time. Example of ethics question: “Given (state uncertainty or conflict about values), what decisions or actions are ethically justifiable?”
  • Determine best process for decision-making: How urgent is the situation? How can stakeholders best be engaged? Who ultimately has decision-making authority? Stakeholders deserve to know and understand how and why a decision that affects them was made. It is important to remember that transparency is not just about the transmission of information; it is also about keeping people engaged constructively in the process. In the rare cases where confidentiality is ethically necessary, the process should still be made as transparent as possible while identifying the confidentiality constraints explicitly.

• Study ​the facts:
  • In any complex situation, different parties will have different views of the facts of the situation. Ideally, all stakeholders should have a chance to present their views to one another in a respectful, open environment, considering both the context of the situation and the evidence.
  • Stakeholder Perspectives: all stakeholders should have an opportunity to voice their views about the issue (staff, community, patients, partners, etc.)
  • Evidence: include risks and benefits to the organisation and patients; impact of situation on quality or services; best practices, etc.
  • Contextual Features: internal and external directives and partnerships (i.e. academic commitments); legal considerations (i.e. agreements, legislation, etc.); past cases; cultural or environmental issues (i.e. staff morale); public opinion
  • Resource Implications: human and financial

• Select​ Reasonable Options:
  • Always look for more than two. Try brainstorming options without evaluating at first, or start by describing your “ideal” solution and work backwards to options that are more realistic given the context.

• Understand ​Values & Duties:
  • Which values are in conflict? Where values may be compromised, what can you do to minimise the negative impact?
  • Are there professional or legal obligations or standards to consider?
  • Consider how various options reflect or support the duties, principles and values

• Evaluate ​& Justify Options:
  • For each option consider: What are the possible harms to various stakeholders?
  • What are the probable benefits to various stakeholders?
  • What will be the impact on staff, our mission and quality of care?
  • Which duties, principles and values support this option?
  • What if everyone in these circumstances did this? (Does this set a good example? Are we making it easier or harder for others to do the right thing?)
  • Does it meet Organisational Justice requirements: procedural justice, distributive justice, relational justice?
  • Does your solution answer the question you described above?
  • Choose the option with the best consequences overall and closest alignment with key duties, principles and values
  • Clearly state reasons for the decision. Remember that you are not aiming at “the perfect” choice, but a good and defensible choice under the circumstances.
  • Anticipate how you might answer criticisms.

• Sustain ​& Review the Plan:
  • Accepting responsibility for an ethical choice means ensuring that the decision made is enacted by articulating a clear plan of action, communicating it to stakeholders appropriately and addressing systems that might have contributed to the problem. It also means accepting the possibility that you might be wrong or that you may need to revise your decision in light of new information or changing circumstances. In reviewing the plan consider:
  • How well did the decision-making process work?
  • Was the decision carried out?
  • Was the result satisfactory?
  • Does this situation point to a systems problem (e.g. policy gap)?
  • What lessons were learned from the situation?
  • How will the team respond to similar situations in the future?
  • Are there opportunities to appeal or modify the decision based on new information?
  • Have new questions emerged? (If so, do they require similar deliberation?)
  • Is there a formal evaluation plan in place to monitor progress, good practices and opportunities for improvement?