MEDICAL HUMANITIES III Ethical decision – making Prof.dr.sc. Marija Definis-Gojanović Split, October2015.

Ethical decision making Ethics involves applying a set of rules or principles to a given set of facts Questions? What are the facts of this situation? What rules or principles apply? How should they be ranked/ordered? How do they apply? Does it matter what the consequences are? Can something be good if it does not (cannot) work? Does individual skill and ability change what a “right” answer or decision might be?

Ethical Problems Problems caused by fact of having to choose between goods or things to which we owe an obligation Bad rankings of goods Failure to grasp facts Ignorance Incompetence Willful blindness Bad factual analysis Often caused by personal or institutional distortion

Organizational Problems General organizational culture Ego and narcissism Overly punitive responses Lack of a culture of responsibility Failure to acknowledge information distortion Bad communication flows High transaction costs for doing the “right” thing

As Practical Ethics, Medical Ethics focuses on: The process of deciding what is the most appropriate (right) course of action in a particular situation given these facts given my skills and abilities operating with knowledge in real time and then effecting that course of action.

Ethical theories and principles as a framework for decision making The traditional but deficient view: simply “applies” a particular ethical theory such as utilitarianism or deontology in a given context This approach adheres to the idea that ethics is quite similar to geometry (principles and general rules can be inferred and then applied to concrete cases independent of the details of the particular case) 20th century: traditional ethical theories had great difficulty in solving the new contemporary problems

Ethical theories and principles as a framework for decision making Deontological Approaches Deontological approaches are commonly characterized by applying usually strict moral rules or norms to concrete cases. Religious approaches, such as those of the Catholic Church, and non-religious deontological approaches, such as Kantian-oriented theories, are prime examples of applying moral rules.

Ethical theories and principles as a framework for decision making Utilitarianism One of the most prominent and influential ways of ethical reasoning and decision making Four important core elements that all utilitarian approaches have in common: 1. The consequence principle 2. The utility principle 3. The hedonistic principle 4. The universal principle

Ethical theories and principles as a framework for decision making The Four-Principle Approach The four-principle approach, often simply called principlism, consists of four universal prima facie mid-level ethical principles: (1) autonomy, (2) non-maleficence, (3) beneficence, and (4) justice. Together with some general rules and ethical virtues, they can be seen as the starting point and constraining framework of ethical reasoning and decision making (“common morality”).

Ethical theories and principles as a framework for decision making Virtue Ethics The general idea of virtue ethical approaches in bioethics is that one should act in accordance with what the virtuous agent would have chosen. That means an action that is morally right (for instance, to help the needy) but performed according to the wrong motive (such as to gain honour and reputation) is not morally good. The right action and the right motive must both come.

Ethical theories and principles as a framework for decision making Casuistry Casuistry had its historical heyday in moral theology and ethics during the period from the fifteenth to the seventeenth century in Europe. After a long time of no importance or influence in moral philosophy, it gained a significant importance in bioethics - mostly in clinical ethics. Casuists attack the traditional idea of simply applying universal moral rules and norms to complex cases in order to solve the problem in question.

Ethical theories and principles as a framework for decision making Feminist Bioethics Historically speaking, feminist ethics developed in strong opposition to the traditional male-oriented approaches which genuinely appealed to universal moral rights and principles, such as principlism, deontological approaches and utilitarianism. Feminist bioethics developed from the early 1970s on and was initially focused on medical ethics; proponents later extended the areas of interest to issues in the fields of animal and environmental ethics.

Professional codes as a framework for decision making Over centuries medical profession has developed its own standards of behavior for its members – expressed in codes of ethics and related policy documents Global level: WMA, UN Principles of medical ethics Ethical directives of medical associations are general in nature but “in making decisions, it is helpful to know what other physicians would do in similar situations”

How do individuals decide what is ethical? Two different ways of approaching ethical issues: Non-rational (not irrational) Rattional

How do individuals decide what is ethical? Non-rational (not irrational) approaches: Obedience - following the rules or instructions of those in authority, whether or not you agree with them (common way, especially by children and those who work with authoritarian structures) Imitation - following the example of the role model Feeling or desire (subjective approach) Intuition - location in the mind (rather than the will) Habit – there is no need to repeat a systematic process each time a moral issue arises similar to one that has been dealt with previously

How do individuals decide what is ethical? Rational approaches: Deontology (search for well-founded rules) Consequentialism (the right action is the one that produces the best outcomes; the best known is utilitarianism uses “utility” as a measure: “the greatest good for the greatest number”) Principalism (often clash of principles) Virtue ethics (a type of moral excellence; important virtues: compassion, honesty, prudence, dedication)

Process of making ethical decisions Awareness—Is there a moral issue here? What is its nature? How important? What are the facts? What are the issues? What rules or values apply here? To whom or what do I owe a duty? How should they be applied? Who needs to decide and act? Who ought to? To what am I obligated because of role/position? What are the consequences? What are the options?!

Framework for ethical decision-making IN PRACTICE Four step problem-solving process: Problem identification (identify: technical facts, moral parameters, legal constraints, relevant human values) Develop alternative curses action (identify: relevant ethical principles for each alternative, recognize ethical assumptions for each alternative, determine additional emerging ethical problems)

Framework for ethical decision-making IN PRACTICE Four step problem-solving process: 3. Select one alternative course of action (justify the selection of your alternative, defend your selection upon ethical grounds 4. Consider objections to alternative selected (objections arising from: factual errors, faulty reasoning, conflicting values)

Framework for ethical decision-making IN PRACTICE Determine whether the issue at hand is an ethical one. Consult authoritative sources to see how physicians generally deal with such issues. Consider alternative solutions Discuss your proposed solution with those whom it will affect. Make your decision and act on it. Evaluate your decision and be prepared to act differently in future.