The RIPS Model of Ethical Decision Making

Original Editor - Wanda van Niekerk based on the course by Andrea Sturm
Top Contributors - Wanda van Niekerk, Jess Bell and Tarina van der Stockt

Introduction

Complex ethical challenges are common in the healthcare environment, requiring careful consideration and a structured approach to decision-making. To make ethical decisions, rehabilitation professionals must be able to recognise sensitive situations and understand the moral values that come into play when considering ethical principles, professional obligations and regulations. The Realm-Individual Process Situation (RIPS) model of ethical decision making is one framework that can guide decision-making, providing rehabilitation professionals with a systematic approach to address the multifaceted nature of ethical decisions.

Complexity and Diversity of Ethical Landscapes

Rehabilitation professionals and physiotherapists often encounter complex, diverse ethical issues in clinical practice. These issues can cause moral distress and influence outcomes and the quality of care.

Previous research has highlighted the variability of ethical situations within and across different world regions. The Ethical Situations in Physiotherapy Internationally (ESPI) study, conducted by Fryer et al., surveyed 1,212 participants from 94 countries across all five World Physiotherapy (WP) regions. This study examined the frequency of 46 ethical situations categorised into four key domains: interactions between physiotherapists and patients, interactions among health professionals, physiotherapists' ethical experiences with their working or health systems, and professional and economic ethical situations. Scarce resources, time constraints affecting quality of care, and limited access to physiotherapy services emerged as the most prevalent ethical challenges globally. These issues persist across diverse healthcare systems, varying physiotherapist-to-population ratios, and different economic contexts.

The ESPI study also highlighted significant socio-cultural variations in ethical experiences, both between and within World Physiotherapy regions. This finding was corroborated in two international studies on the ethical decision-making of physiotherapists, and underscores the contextual complexity of ethical experiences in physiotherapy practice.

As a supplementary component, participants were invited to share ethical experiences beyond the predefined survey items. This open-ended approach unveiled an extensive range of ethical situations—both variations of the original survey scenarios and entirely new ethical challenges. For example, the researchers identified almost 50 shades of just one ethical situation (“Physiotherapist aware of misconduct by other health professionals including other physiotherapists”) in the participant responses. This vividly illustrates the multifaceted nature of the ethical experiences of physiotherapists, spanning individual, interpersonal, organisational, and systemic levels. The new ethical situations identified were grouped into four new themes: lack of regulatory and/or accreditation policy and infrastructure, a lack of recognition of the physiotherapist's role and position in healthcare, economic factors that drive practice conduct, and political threats.

In all areas of clinical rehabilitation, professionals must navigate increasingly complex ethical situations with careful deliberation and reasoning. To be able to do this, rehabilitation professionals need to:

• be informed and “knowledgeable about ethical principles and theories”
• be aware of their professional obligations
• be aware of rules and regulations that apply to their specific scope of practice
• critically reflect on personal and professional values and experiences, their own as well as those of their clients
• prioritise ethical values
• identify and analyse an ethical situation and the contributing internal and external factors
• be aware that ethical, responsible decision-making “requires determining and implementing a plan of action”

It is clear that ethical decision-making is not a linear process, but rather a process with various overlaps.

Realm-Individual Process-Situation (RIPS) Model of Decision Making

The Realm-Individual Process-Situation (RIPS) is an ethical decision making framework for rehabilitation professionals that can be used in any ethical context.

Components of the RIPS Model

The main components of the RIPS model (Realm, Individual Process, Situation) are discussed below.

Realm

There are three "realms": the individual realm, the organisational / institutional realm and the societal realm.

The individual realm focuses on patient / client wellbeing. It deals with direct person-to-person responsibilities and interactions and considers individual rights, personal duties, relationships between people and individual behaviours. It is the least complex level of ethical problems.

The organisational / institutional realm focuses on the good of the organisation. It involves structures and systems to achieve the goals of the organisation / institution.

Finally, the societal realm focuses on "the common good". It is the most complex realm.

Individual Process

Ethical decision-making often embraces several, intertwined processes. A healthcare professional needs moral sensitivity to help them recognise, interpret and frame various ethical situations. They also need to make a moral judgement to determine if something is right or wrong. This process "involves generating options, selecting and applying ethical principles".

If an individual is going to act to change a situation for the better, they will need moral motivation. This means they must choose "ethical values over any other values", such as self-interest, status, or financial gain. They will also need moral courage to implement the ethical action they have chosen. They will need to develop a plan and continue despite any barriers and adversity.

Situation

Finally, we consider the type of "situation" - i.e. is there an issue or problem where important values are present or may be challenged? The ethical situation should be classified as an ethical issue or problem, a dilemma, distress, temptation, or silence.

An ethical dilemma is when two equally valid duties / obligations exist but it is not possible to fulfil both. This represents a "right vs right" decision and both options serve important values.

Moral distress occurs when you know the correct action but lack the authority to execute it. Moral distress often surfaces during the implementation phase of decision making.

Moral temptation involves choosing between right and wrong, but in these situations, an individual may benefit from doing the wrong thing.

Silence is another common ethical situation. In these cases, ethical values are challenged, but no one is addressing or discussing the challenge. Silence may occur when someone is experiencing moral distress. It is a passive response to ethical concerns.

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Examples of the RIPS Model for Ethical Decision Making

Please read the following examples of ethical issues and how they can be analysed using the RIPS model. Note that the realms are interdependent, and the complexity of a problem increases as you move through the different realms. In many situations, one realm will be more important, but in every situation all realms are impacted.

Example 1: A rehabilitation professional discriminates against a patient on the basis of age, gender, appearance, culture or religion by refusing to treat, showing a lack of respect for cultural beliefs or providing poor-quality treatment.

Realm	Individual Process	Situation
Individual The rehabilitation professional's personal attitude, beliefs, biases, and ethical standards influence the quality of care. These values can hinder or support equitable treatment, how the professional interacts with patients, and whether they respect diversity and cultural beliefs. Organisational or institutional Organisational policies are important in guiding non-discriminatory practices and cultural competence. When these policies are in place, the rehabilitation professional's actions also reflect the organisation's reputation and culture. If these policies are absent, the professional's ethical standards and adherence to broader professional ethics become essential for guiding non-discriminatory behaviour. Societal This is related to broader societal values such as respect, fairness and equality, which are vital in healthcare.	Moral sensitivity The rehabilitation professional must be aware that their actions are discriminatory and this could harm the patient or deny them their right to quality care. Moral judgement The professional should assess whether their behaviour aligns with their profession's ethical principles such as fairness and respect for others, and consider the ethical standards in their professional code. Moral courage The professional may need to demonstrate courage by upholding ethical standards and overcoming personal biases or social pressures to treat the patient fairly.	Moral distress If the rehabilitation professional recognises their behaviour as wrong but feels pressured to act according to personal biases or cultural assumptions, this could lead to distress. Moral temptation The professional might be tempted to act on personal biases and stereotypes, even if they know these actions are unethical.

Example 2: Due to limited resources and time, the quality of rehabilitation may be compromised, affecting patient outcomes.

Realm	Individual Process	Situation
Individual The clinician's professional ethical standards to provide quality care may be strained by time and resource limitations, forcing them to make difficult decisions about care prioritisation. Organisational / institutional The organisation is responsible for the effective allocation of resources and for supporting its staff to maintain quality of care. Resource limitations may reflect on broader issues within the organisation, which can influence the care the rehabilitation professionals can give. Societal There is a broader societal expectation that healthcare should be fair and equitable. This expectation is challenged if only some clients receive optimal care due to time and resource constraints.	Moral sensitivity The professional must recognise that reduced resources directly affect patient outcomes and may prevent them from delivering optimal care. This could lead to ethical concerns about the quality of care they can provide. Moral judgement The professional should weigh the ethical importance of optimal care against the reality of limited resources and decide how to best use their skills and resources to benefit patients as much as possible. Moral courage The professional may need to advocate for extra resources, voice their concerns about quality of care or find creative solutions to reduce the impact of limitations.	Ethical dilemma There is an ethical dilemma in balancing quality of care with the constraints imposed by limited resources. It may be difficult for professionals to reconcile their duty to provide optimal care with the reality of limited resources. Moral distress The professional may experience distress if they are unable to meet their standards of care due to resource limitations and may experience frustration or guilt over patient outcomes being negatively affected. Moral temptation The temptation could be to lower care standards to handle the resource limitations, even if the professional feels this will compromise their integrity and well-being.

Implementation of the RIPS Model for Ethical Decision Making

The four steps of the ethical decision making process are:

1. Recognise and define the ethical situation
2. Reflect
3. Decide the right thing to do
4. Implement, evaluate and re-assess

Application of the RIPS Model of Ethical Decision Making: A Case Scenario

Souza et al. recently published a case study applying the RIPS model in ethical decision making to ageing and ethical challenges in physiotherapy. You can read the case study here: Ageing and ethical challenges in physiotherapy: application of the RIPS model in ethical decision making

Below is a summary of the case study and the application of the RIPS model as described in the case study.

The case study highlights some ethical challenges that physiotherapists can encounter when treating older people. It highlights how our ageing populations have led to new ethical challenges, especially regarding decision making. Key concerns associated with an ageing population include how we can (1) manage older people's fragility, (2) avoid paternalistic attitudes from healthcare professionals and family, (3) balance professional ethics with family system values and (4) preserve and advocate for patient autonomy.

Specific case study:

A 75-year-old man was transferred from a hospital to a long-term care facility. The man is alert and oriented. He reports being hospitalised for shortness of breath and weakness and believes he just needs physiotherapy before returning home. The family privately informs the physiotherapist that the patient has stage 4 inoperable lung cancer and he only has a few weeks to live. The family has intentionally withheld this diagnosis from the patient and requested that the staff not disclose the diagnosis to the patient. The physiotherapist decides to refer this issue to the facility's ethical board.

Summary of the RIPS application in this case scenario

Step 1: Recognise and define the ethical situation

• Realms:
  • individual realm: issue within the relationship between the physiotherapist, the patient and the patient's family
  • societal realm: society's perception or beliefs about older people and ageing - for example, that older people cannot make their own decisions if they are frail and ill

• Individual process:
  • moral judgement: the physiotherapist needs to decide what to do about this situation (speak to the patient or respect the family's wishes)
  • moral motivation: putting ethical values above the family's wishes
  • moral courage: implement the decision of talking to the patient and being honest about their diagnosis

• Situation:
  • this situation is an ethical dilemma and it focuses on the conflict between patient autonomy and the family's wishes to withhold information from the patient - should the physiotherapist be honest with the patient or respect the family's wishes?

Step 2: Reflect

The reflection step involves examining the situation, considering the facts, such as the life and death nature of the situation and the family's desire to keep the diagnosis from the patient. It also requires consideration of stakeholder opinions. Reflection should include an ethical analysis, incorporating principles of professional deontology (good versus bad actions), and weighing the potential consequences of the decision.

Step 3:Decide the right thing to do

The physiotherapist decides to inform the patient about their diagnosis after speaking to the family about it.

Step 4: Implement, evaluate and reassess

The physiotherapist decides that the information about the diagnosis should be given by a physician, who can answer any medical questions that the patient may have, provide information about the prognosis and address life expectancy concerns.

Summary of discussion and conclusion of the case study

Rehabilitation professionals are confronted with various ethical and regulatory issues in clinical practice, but most rehabilitation professionals find it difficult to identify and analyse ethical situations. We need to also recognise that various external factors can influence decisions about patient care.

The RIPS model is a useful tool in varying situations and contexts as it promotes professional growth, provides a useful framework for ethical decision making across various clinical contexts and demonstrates that ethical approaches should not be different based on specific populations.

This case study raises several important points relevant to healthcare practitioners working with older adults, namely the need to balance the awareness of age-related incapacities with respect for patient autonomy, the risk of paternalism and benevolent decision making and the fundamental principle that older people have the same rights as other people.