Ethical Reasoning Bridge
Original Editor - Wanda van Niekerk
Top Contributors - Wanda van Niekerk, Jess Bell and Tarina van der Stockt
Introduction
Ethical decision-making in healthcare can be complex, requiring a practitioner to consider several fundamental but sometimes conflicting factors. Ethics has both a regulatory function, establishing professional standards and codes of conduct, and an introspective one, where practitioners examine the underlying values, assumptions, and contextual conditions that shape human behaviour and moral decision-making.[1]
The Ethical Reasoning Bridge (ER Bridge) is a framework developed through research in physical therapy. It presents a different way of thinking about clinical practice, ethical decision-making, and patient care. It recognises that effective healthcare needs more than just technical skills; it also requires an understanding of human experience, socio-economic contexts, and individual capabilities.[1]
Decisions in Clinical Practice
Clinicians should be able to explain, justify and validate their diagnostic and treatment decisions. Various models exist in healthcare to help clinicians with data gathering and clinical decision-making, such as the ICF model and evidence-based practice (EBP). However, making sound clinical decisions involves more than just following models. Clinicians should apply clinical reasoning strategies to select and use the most appropriate treatment strategies. Ethical reasoning is just as important. Ethical reasoning requires clinicians to have a good understanding of professional ethics and professional codes of conduct, as well as knowledge of the underlying principles of ethics, such as respect for autonomy and justice. Finally, clinicians should be aware that their personal beliefs may also influence their clinical decision-making.[1]
Features of the ER bridge
The ER bridge framework has three key features. Firstly, it considers the relationship between different types of ethics (an epistemological approach or knowledge-theoretical approach) and how these relationships are understood. Secondly, it is dialectical, demonstrating how various forms of knowledge interconnect to facilitate learning and action. Thirdly, the symbolic or mental movement of crossing and recrossing the bridge when reasoning, making decisions, taking action and reflecting, emphasises how clinicians and eventually patients, are involved in the same process of developing moral agency.[1]
Moral agency is the ability of individuals or collective entities to make ethical decisions based on what is right or wrong. It "encompasses cognitive capacities, feelings, skills and actions" that occur in a specific situation.[2] Three major concepts are included in moral agency[3]:
- the moral competency of the individual or collective entity in question
- the normative framework on which ethical behaviour is based
- the situational constraints that influence decision-making
The Two Sides of the Bridge
Conceptually, the ethical reasoning bridge has two distinct but interconnected sides. Each side represents a different approach to understanding human experiences and decision-making.[1]
The normative ethics side of the bridge depicts the world of healthcare practitioners. This world includes universal ethical practices, such as beneficence, non-maleficence, respect for autonomy and justice. These ethical practices traditionally form the basis of different professional codes of conduct.[4] This ethical approach is also referred to as "third-person" ethics. It represents the rationalist and deductive methods of scientific problem solving as it applies universal or general principles to predict a specific outcome in specific ethical dilemmas (deductive reasoning). Using these features of rationality, generalisability, measurability and predictability in diagnostic reasoning allows clinicians to focus on what they "ought to find" and what they "ought to do" when assessing and treating patients.[4] This form of normative ethical problem-solving is described as "a rigorously rational, formal, largely deductive mode of argumentation."
The relational / descriptive ethics side of the bridge represents the world of patients, caregivers and the community. Relational ethics is defined as "an action ethics that is placed within interpersonal relationships."[5] This approach is sometimes referred to as "first-person" ethics. Narrative reasoning is applied to understand an individual's lived experiences of their injury / illness and its impact on their quality of life, their sense of identity and moral striving in specific contexts. In this way, hypotheses related to factors, such as an individual's motivation, beliefs and attitudes, are more likely "generated" rather than tested.[1] This side of the bridge acknowledges that the truth and reality of a situation are dependent on the context of the situation and that multiple realities may exist. It also acknowledges the fact that knowledge can be socially constructed. It implies that an individual's or community's understanding and interpretation of their experiences will influence their decision-making and their actions. It can also lead to "adaptive preferences" (i.e. expectations can change due to the influences in a specific context). This side of the bridge provides insights into what an individual "actually does."[1]
A figure of the ethical reasoning bridge framework can be downloaded from here.
Crossing and Recrossing the Bridge: A Dynamic Ethical Reasoning Process
The power of the ethical reasoning bridge lies in the dynamic process of crossing and recrossing the bridge, or in other words, moving between the two different processes of deductive and inductive reasoning. When clinicians cross and recross the bridge during data gathering and clinical reasoning, they engage in a form of wide reflective equilibrium and dialectical reasoning, where they consider different versions of reality.[7]
Reflective equilibrium is "a method used in ethical decision making to reflect on a perspective or judgement to reach a justified moral position between competing moral judgements."[1] [8] According to Ian Edwards, clinicians using reflective equilibrium would ask themselves what they are doing in a specific situation.[9]
Wide reflective equilibrium expands on the concept of reflective equilibrium. It is argued that reflective equilibrium "is not sufficient to understand another person's lived experience and perspective; it is also important to understand the social, cultural, socioeconomic and other environmental conditions that inform and shape that lived experience and perspective."[1] Wide reflective equilibrium offers a broader perspective. According to Ian Edwards, clinicians engaging in a form of wide reflective equilibrium realise they need to go further than just considering their own ideas and thoughts. Thus, they find out what others (e.g. patients, caregivers, colleagues) think. They seek the perspectives of others to inform their perspectives.[9]
Dialectic is defined as "a tension that exists between two fundamentally different processes or ideas where neither process is regarded as intrinsically truer than the other and where each contributes to an understanding of the other."[1] [10] Or in simpler terms, two truths might be different but one doesn't have to be more true than the other.
Together, dialectical reasoning and wide reflective equilibrium can lead to a "coherence of factors", such as knowledge, values, and perspectives, which contribute to a moral judgement, as well to the capacity to reflect on, revise or transform an initial understanding or perspective. This reflection, revision and transformation can lead to transformative learning.[1][9] [11]
Transformative learning is a process that can help clinicians become more open-minded, thoughtful and emotionally flexible. It can help clinicians identify more nuanced perspectives, question existing beliefs and foster a willingness to change how they feel and think about complex ethical dilemmas.[11] Clinicians need to be able to reflect on their own beliefs and perspectives, being aware that sometimes strong convictions can also be their prejudices. Clinicians must also understand the beliefs and perspectives of their patients. Remaining open to new knowledge, experiences and evidence is important even if it challenges existing beliefs. Clinicians should strive to make informed, fair and thoughtful decisions that improve and prioritise patient care, professionalism and integrity.[1]
Conclusion
The ethical reasoning bridge provides a pragmatic approach to ethical decision-making. Through the integration of normative ethics with relational (non-normative) ethics, the framework encourages clinicians to engage in a dynamic and reflective process of understanding. Through this approach, it is clear that effective healthcare requires more than technical expertise, it also requires a deep understanding of human experiences and contexts.[12] By crossing and recrossing the bridge, clinicians can develop transformative learning skills, examine their assumptions and appreciate the value of multiple perspectives from others. This equips clinicians with ethical reasoning skills that are rooted in principles, but are also deeply humanistic.
As a reminder: the therapist is always situated at the normative side of the bridge, and crosses and recrosses it to the patient's narrative side (and vice versa). Both parties, patient and therapist, learn from each other (in the ideal scenario), but are situated differently.
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Edwards I, Delany CM, Townsend AF, Swisher LL. Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice. Physical Therapy. 2011 Nov 1;91(11):1653-63.
- ↑ Elmersjö M, Hultqvist S, Hollertz K. Moral stress and moral agency in Swedish eldercare. Social Science Protocols. 2022 Apr 10;5(1):1-0.
- ↑ Christen M, Van Schaik C, Fischer J, Huppenbauer M, Tanner C, editors. Empirically informed ethics: Morality between facts and norms. Cham, Switzerland: Springer International Publishing; 2014.
- ↑ 4.0 4.1 Gustafson AB. Normative ethics. In: Encyclopedia of Business and Professional Ethics, 2023 May 25 (pp. 1415-1419). Cham: Springer International Publishing.
- ↑ Tomaselli G, Buttigieg SC, Rosano A, Cassar M, Grima G. Person-centered care from a relational ethics perspective for the delivery of high quality and safe healthcare: a scoping review. Frontiers in public health. 2020 Mar 6;8:44.
- ↑ Flip4Learning at Alvernia University. Normative and Non-Normative Ethics. Available from: https://www.youtube.com/watch?v=JVVF2t54Xlg [last accessed 13/12/2024]
- ↑ Delany C, Edwards I. From Ethical Reasoning to Ethical Action. InClinical Reasoning and Decision Making in Physical Therapy 2024 Jun 1 (pp. 47-56). Routledge.
- ↑ Rawls J. A theory of justice: Revised edition. Harvard university press; 2020 Jul 27.
- ↑ 9.0 9.1 9.2 Sturm A. Ethical Reasoning Bridge Course. Plus, 2024.
- ↑ VanderKaay S, Letts L, Jung B, Moll SE. Doing what’s right: A grounded theory of ethical decision-making in occupational therapy. Scandinavian Journal of Occupational Therapy. 2020 Feb 17;27(2):98-111.
- ↑ 11.0 11.1 Christensen, N. Jensen, GM. Developing clinical reasoning capability. In: Higgs J, Jensen GM, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. Edinburgh: Elsevier. 2024
- ↑ Sturm A, Roth R, Ager AL. Views of physiotherapists on factors that play a role in ethical decision-making: an international online survey study. Archives of Physiotherapy. 2023 Feb 1;13(1):3.