MAKING ETHICAL CHOICES An Ethical Decision-Making Handbook for Health Care Practitioners & Administrators Second Edition

Full text

MAKING ETHICAL CHOICES
An Ethical Decision-Making Handbook for
Health Care Practitioners & Administrators
Second Edition
Steve Abdool
Edgardo Pérez
Wilson Lit

MAKING ETHICAL CHOICES
An Ethical Decision-Making Handbook for
Health Care Practitioners & Administrators
Second Edition

Making Ethical Choices
An Ethical Decision-Making Handbook for Health Care
Practitioners & Administrators
Steve S. Abdool
Bioethicist & Director,
Regional Centre for Excellence in Ethics,
Homewood Health Centre
& Ethicist at the University of Toronto
Edgardo L. Pérez
CEO & President,
Homewood Corporation,
Professor of Psychiatry, University of Toronto
Wilson M. Lit
Chief of Medical Staff,
Homewood Health Centre,
Associate Professor, McMaster University
All Rights Reserved
Copyright © Steve Abdool, 2000
Second Edition, 2010
Cover art derived from Paul Gauguin’s Portrait of the Artist with the
Idol, c. 1893.
This handbook may not be reproduced in whole or part without
permission from the authors

We would like to thank our families as well as friends and colleagues
at the Homewood Health Centre for their support and encouragement.
Special thanks are also due to Jill Herne and Reid Finlayson for their input
and insights. Without them all, this handbook would not be possible.
Steve Abdool, Edgardo Pérez and Wilson Lit

Contents
Cases 1
Introduction 3
Considerations in Health Care 7
Ethics 8
Ethical Approaches 9
Dening Ethical Decisions 12
Ethical Dilemmas 14
Ethical Consensus 15
The Team 18
Effective Team Deliberation 19
Pitfalls to Avoid 22
Fallacies 24
Personal Values 27
Moral Reasoning 30
The Law 32
Professional Codes of Ethics 33
Institution’s Mission, Values, Policies & Practices 35
Ethical Principles & Guidelines 37
The Virtues 40
Ethical Decision-Making Model 42
Conclusion 53
Case Study 54
Endnotes 59
Bibliography 69
Appendix 1: Canadian Medical Association Code of Ethics 71
Appendix II: Canadian Nurses Association Code of Ethics 75

“Human beings owe each other help to distinguish the better
from the worse, and encouragement to choose the former
and avoid the latter. They should be for ever stimulating
each other to increased exercise of their feelings and
aims towards wise instead of foolish, elevating instead of
degrading, objects and contemplations”
John Stuart Mill, On Liberty

Making Ethical Choices
1
Cases
A starving patient with anorexia who refuses nutrition or
hydration
Miss Jones is a 45 year-old single woman with a 12 year history of
severe anorexia nervosa. She was admitted because of ambivalence about
life and rapidly decreasing weight – 69 pounds, which is approaching a
dangerously low level given her height. Miss Jones is only ingesting
small amounts (sips) of water. She denies active suicidal ideation or
plan. She has had at least 7 admissions in the previous 5 years, and she
was force-fed on 1 occasion. All therapy has so far failed. Although she
sometimes feels that she would be better off dead, Miss Jones does not
believe that her life is being compromised by her refusal of hydration
and nutrition. She emphatically refuses to be force-fed, claiming that
it had previously been a very degrading experience and violated her
basic values and beliefs. There is disagreement amongst the team (which
includes 2 physicians) concerning how to care for Miss Jones in this
situation. Miss Jones’ closest relative, her father, feels that he is not in
a position to override his daughter’s wishes. What ought to be done?
Why?
A depressed man with newly discovered prostate cancer
Mr. James is a 67 year-old gentleman who has practically given
up on life since his wife and daughter recently passed away 6 months
previously in a car accident. Since this unfortunate incident, he sleeps
most of the time, barely eats, and lives a very reclusive lifestyle. He
admits to feeling suicidal at times, and he is currently being treated
in hospital for clinical depression. During routine examination and
assessment, it was discovered that Mr. James has prostate cancer with
possible metastases. The prognosis is poor. Should Mr. James be told
about his medical condition? Why?
An intimate relationship between 2 co-patients
Mrs. Smith is a 25 year-old married woman who was admitted
into hospital for the treatment of clinical depression. On admission,
she was accompanied by her husband and 3 young children. Her family
seems very supportive, and she wanted to include them in her recovery
process. 3 weeks later, the team discovers that Mrs. Smith is having an
intimate relationship with a male co-patient (whose diagnosis includes
personality disorder). The team is aware that this male patient recently

Making Ethical Choices
2
Making Ethical Choices
3
had an intimate relationship with another co-patient and he generally
practises unsafe sex. He was not prepared to divulge this information to
his new partner. What should the team do? Why?
The pregnant patient suffering from schizophrenia
Miss Grant is a 34 year-old single patient who was admitted for
threatening behaviours toward her elderly mother. She has a 15 year
history of paranoid schizophrenia, and she is often non-compliant with
her medication. Miss Grant generally lives on the street where she
frequently abuses a variety of drugs and engages in unsafe sex. After 3
weeks of treatment in hospital, it was discovered that Miss Grant was 14
weeks pregnant. She appeared shocked at this discovery. Her capacity
uctuated rapidly – she would insist on procuring an abortion one
moment, then deny, within minutes, that she was even pregnant. Miss
Grant’s mother was her substitute decision-maker. She wishes to have
her daughter carry the foetus to full term. Once Miss Grant’s condition is
stabilized, she will inevitably return to the street and would most likely
continue to abuse drugs and practise unsafe sex. What should be done?
Why?
A limb versus a life
Miss Gardner is a 74 year-old single woman who was admitted for
a femoral arterial graft. She experienced a cardiac arrest during surgery.
Although Miss Gardner was successfully resuscitated, she needed to spend
about a week in the Intensive Care Unit. Her medical history includes
mild cardio-vascular heart disease and a stroke ten years previously. Miss
Gardner recovered from her stroke with only minimal physical decits.
Following surgery, she developed a severe psuedomonas infection of her
graft, which formed an articial aneurysm. Miss Gardner’s aneurysm
could rupture at anytime and she would die. Alternatively, her surgical
predicament could be resolved by having a high leg amputation. Miss
Gardner emphatically refuses any further surgical intervention, stating
that she has had enough and wishes to die. Miss Gardner appears to
possess competency to consent to, or refuse, treatment. What ought to
be done? Why?
Introduction
Health care practice and administration is fraught with complex
moral issues and dilemmas. Shifting paradigms in the health care system,
such as limited resources, increased emphasis on patients’ rights, and
moral diversity, have profound and far-reaching ramications that impact
us all – health care recipients and their families, health care professionals
and administrators, and other stakeholders.
On the one hand, advances in medical technology have created
renewed hope and exciting horizons in our quest for cures and treatments
of illnesses that cause pain, suffering and, frequently, premature death.
On the other hand, the development of new investigative and treatment
techniques have added complex and bafing ethical questions to old
moral quandaries in health care.
Generally, health care professionals and administrators
conscientiously follow personal or interdisciplinary frameworks for
making decisions. These processes are enmeshed with a wealth of
professional and personal experiences. Yet, how often is the health
care professional or administrator bafed by difcult and perplexing
circumstances that possess a value foundation. Commonly asked
questions include: Which of these difcult alternatives should I choose?
What course of action is most appropriate in this situation, and who
should so decide? Answers to questions such as these often have very
far-reaching ramications, and they may on some occasions determine
whether a patient is treated fairly or, indeed, whether he lives or dies.
Arguably, current ethical decision-making models are inadequate
and may even be perilously deceptive (by purporting to deliver sound
moral choices through over-simplied models or checklists) in claiming
to produce effective and morally justiable decisions. This handbook is
the result of an appraisal of major bioethical decision-making processes.
These models include Brody’s Model,1 Bunting and Webb’s Model,2
Thompson and Thompson’s Model,3 Murphy and Murphy’s Model,4
Aroskar’s Model,5,6 Curtin and Flaherty’s Model,7 Grundstein-Amado’s
Model,8 Laurence McCullough’s Model,9 Jonsen, Siegler and Winslade’s
Model,10 College of Nurses of Ontario’s Model,11 and Chidwick’s
Model.12
This decision-making model has been peer-reviewed and evaluated
for external validity in several health care institutions by administrators,
clinicians and patients. It proves to be invaluable to stakeholders in the
microcosms of institutional activity while, at the same time, contributing
to our efforts to enhance justice and benevolence in the macrocosm of

Making Ethical Choices
4
Making Ethical Choices
5
our general society.
Health care administrators and policy makers use the same logical
process as clinicians in deriving ethical conclusions to moral quandaries
that they face. The basic questions follow the same sequence, for
example, “What is really at stake?” “Who are the stakeholders?” “How
does it impact this business?” “What are the external constraints?” and
“Which of the various options most conform to the ethical principles
of justice and decency while retaining other legitimate interests (for
example, duties to stakeholders such as the general public and insurance
agencies)?”
The decision-making model offered in this handbook takes into
consideration the following realities: First, doctors are no longer sole
proprietors of health care delivery. Increasingly, patients are insisting
upon their inclusion and active participation in decisions involving their
care and treatment. Patients are now dependent upon several disciplines
of health care professionals for the provision of appropriate care and
treatments. Additionally, front line health care professionals possess
increased empowerment, each functioning within his/her legitimate
competencies. There is, therefore, a shifting paradigm in health care
delivery from a paternalistic and autocratic modus operandi to a patient-
centred, multidisciplinary and, therefore, democratic approach.
Second, while demanding greater individual accountability and
responsibility as health care professionals and administrators, there
is an increased expectation that hospitals and community health care
organizations will form partnerships. They will hopefully work together
in making important decisions to provide efcient and effective
treatments in an uninterrupted continuum of care to patients. These new
alliances, some institution-based and others community-based, have
their own cultures, norms and philosophies with years of practices in
relative isolation. Not surprisingly, then, collaborative decision-making
poses an enormous challenge as the alliances attempt to develop common
frameworks and policies through shared values and priorities.
Third, ethical knowledge and analytical skill remain sporadic and
decient in the training curricula of health care professionals as they are
for health care administrators. There is a lack of a consistent, coherent
and comprehensive decision-making process in directing health care
professionals and administrators to rationally, systematically and effectively
resolve ethical dilemmas. Consequently, patients – the primary purpose
of having a health care system – experience inappropriate choices in care
and treatment modalities. They can sometimes endure immeasurable and
unnecessary pain and suffering, prolongation of institutionalization – a
waste of vital nite resources – and the indignity of a loss of freedom
and privileges. Health care providers and administrators may experience
a great deal of anger, frustration, and emotional distress that reects in
their private lives and health, as well as in their professional lives, and
patients and their signicant others suffer immense ramications from
reduced quality of care and treatment.
Fourth, the microcosmic structure of the health care institution itself
can be a potential source of difculties, for example, conict of interests
and loyalties. The way that the administrative structure is designed
usually creates a hierarchical system with individuals wielding varying
degrees of power and authority. Indeed, such a structure might be quite
necessary as it serves to ensure the smooth and efcient operation of the
institution. However, authority and power must be harnessed through
ethical deliberation and conduct, and, arguably, the greater the thrust
toward a democratic process, as a safety mechanism, the greater the
possibility for the achievement of just, fair, and non-discriminating
decisions within the facility.
Finally, this ethical decision-making process takes into consideration
the cultural diversity and moral plurality of our evolving society. From a
realistic and pragmatic perspective, it recognises that it is not uncommon
to nd individuals, professionals and lay people alike, whose moral
positions are the exclusive result of intuition, usually lacking in moral
profundity and discernment. Its process is respectful of, and sensitive
to, individuals’ autonomy – their feelings, thoughts, beliefs and moral
convictions – even when these are sometimes obscure and amorphous.
This model considers the realism of moral plurality an advantage
and, with the welfare of the patient as the primary focus of attention,
engages an appeal to the consciences and convictions of its members
through rational discourse and argumentation, to arrive at a choice that
is most appropriate under the circumstances. As an eclectic and dynamic
process, it engages the collective, committed, and collaborative efforts of
all legitimate stakeholders in yielding the right choice.
A most appealing aspect of this model is that it offers a philosophically
sound and reective process on pressing ethical problems in clinical
practice which would yield a sort of ‘street level’ deliverable philosophy.
That is, it does not necessitate an in-depth understanding and knowledge
of philosophical theorising by all team members. This methodological
ethical decision-making process provides for fair decision-making
for patients, health care professionals, and administrators, such that

Making Ethical Choices
6
Making Ethical Choices
7
everyone, including society at large, may be condent that institutional
decisions are not arbitrary, malevolent, or ill-informed.
The cardinal values that this decision-making process espouses
are (i) patient autonomy (or right to self determination) which respects
individual dignity and worth, (ii) professional and personal integrity
(which respects the right of decision makers to deliberate and act in
accordance with their consciences), (iii) patient’s well-being and best
interest (a primary goal for care intervention), and (iv) justice (as it
applies to access to adequate and reasonable care and to the distribution
of health care resources).
Considerations in Health Care
Codes of
ethics
Law of the land
Patient’s
values,
wishes and
preferences
Hospital
values, mission,
& mandate
Hospital’s duties &
obligations
Clinical info
History info
Examination
Hypothesis testing
Diagnosis
Prognosis
Resources
Time constraints
Third Party
considerations:
society
family
other patients
insurance
Professionals’
duties and
obligations to patient
Duty to profession
Always strive to do
the very best for one’s
individual patients?
Always opt for the
cheapest treatment? Is society safe under
these circumstances?
What is my priority?
Maximize autonomy?
What is my role?
Keep this condential?
Treat this patient rather
than that one?
Does the end justify
the means?
Use scarce resources for
the greatest benet?
Respect patient’s
wishes?
Who are the
stakeholders?
Tell the truth?
Always opt for the best
treatment?

Making Ethical Choices
8
Making Ethical Choices
9
Ethics
Ethics or morality is the reective and analytical study of morals.
It is the branch of philosophy that critically considers what is “right”
or “wrong” and “good” or “evil” in all matters of human conduct.
Anything that has a value component – rights and entitlements, duties
and obligations, meaning, justice and fairness – is ethical in nature.
Ethics in the health care context is commonly known as Bioethics.
Bioethics may be dened as the analytic activity in which the concepts,
assumptions, beliefs, attitudes, emotions, reasons, and arguments
underlying medico-moral decision-making are critically scrutinized.
Medico-moral decisions are perceived to be those that concern norms or
values, good or bad, right or wrong, and what ought to be done in clinical
practice.13
In health care, there frequently exist competing and conicting
values and interests in a context of limited resources, shifting clinician
roles and responsibilities, innovative medical technology, as well as
cultural, religious, and moral diversity. Examples of ethical issues in
health care include genetic manipulation, civil commitment, withholding
and withdrawing life-sustaining treatments, cloning, medical research,
abortion, euthanasia, informed consent, allocation of nite resources,
enforced treatments, and a host of other pressing health related issues
that impact us all.
As a discerning process, then, Bioethics ensures a methodology of
rigorous ethical analysis and sound argumentation in the identication,
resolution, and prevention of ethical dilemmas in clinical practice.
Biomedical ethics distinguishes itself from law by enquiring deeper into
the essence of rational existence and moral conduct, and it distinguishes
itself from religion and personal opinions by requesting rational
justication rather than offering simple ‘rationale’, for example, an
appeal to authority.14
Ethical Approaches
There are at least three different philosophical perspectives to
the resolution of moral dilemmas. First, there is the ‘theory-based’
approach. Two of the commonest ethical theories in health care are
utilitarianism and deontology.15
Utilitarianism takes the position that the morally right action
focuses on consequences by promoting the greatest balance of happiness
over pain. John Stuart Mill (1806-1873), a British philosopher and
politician, was one of the most avid classical utilitarians, and discussions
around utilitarianism hinge on his theory.16 While utilitarianism remains
an extremely compelling ethical theory, one of the most important
objections made against it is that it could permit the treating of rational
beings as mere means, rather than as ends.
Deontology, on the other hand, considers morality in terms of
rules that have intrinsic moral value, irrespective of outcomes. Truth-
telling and promise-keeping are examples of typical moral requirements.
The deontological ethical theory that is primarily used in health care
is derived from a German philosopher, Immanuel Kant (1724-1804).
Kant’s deontology forbids us to treat human beings as mere instruments
to our ends without respecting the fact that they too have ends. We
must treat each person with respect and dignity. Another very important
maxim of his philosophy holds that by making a certain ethical choice I
also give permission to everyone else to act likewise in morally similar
circumstances.17 For example, in order for it to be morally acceptable
for me (as a health care professional) to have an intimate relationship
with one of my patients, it should be acceptable for all health care
professionals to develop intimate relationships with their patients under
similar situations.
It is from such theories that major moral principles are derived,
for instance, benecence, non-malecence, respect for autonomy,
and justice. (These principles will be described later on page 33.) It is
highly desirable to focus on the various ethical principles rather than
the ethical theories in attempting to resolve ethical dilemmas. Exploring
ethical theories at the discussion table could accentuate differences of
perspectives and side-track from the pragmatic issues. Having said this,
it sometimes becomes necessary to examine the theories, the basis if you
will, for the moral principles themselves. This is one of the reasons why
it is extremely important for at least one member of the team to possess
sound ethical knowledge and argumentation skills – increasingly, the
Bioethicist fulls this role.
Ethics
Anything involving values
Rights - Duties - Obligations -
Justice - Fairness - Meaning

Making Ethical Choices
10
Making Ethical Choices
11
Second, the ‘casuistry approach’ typically utilizes particularities
and circumstantial detail as well as maxims in order to arrive at ethical
decisions. It is noteworthy that Western judiciary systems are casuistic
in their methodology of case analysis. It also considers precedent-setting
cases.18
Third, the ‘consultative approach’ promotes open discussion and
dialogue among team members.19 To date, none of these approaches have
offered a categorical and unequivocal moral perspective in analytically
negotiating moral dilemmas.
Each of these valid ethical approaches offers valuable and cogent
arguments, and bears legitimate considerations in the ethical decision-
making process. This decision-making model takes the position that
the multidisciplinary team approach, as a vital aspect of the ethical
decision-making process, is most conducive to the best morally
weighted and rationally considered choice in today’s clinical setting and
in the predictable future of the health care system. In such a diverse
environment, the ethical decision-making process must also be able to
appreciate and accommodate each valid ethical approach.
It is not the purpose of this handbook to undertake a detailed analysis
of ethical theories or principles, or of meta-ethics20 and descriptive
ethics.21 These require elaborate ontological and epistemological inquiry
and argumentation that are beyond the scope of this text. With respect to
meta-ethics, it should be borne in mind that: (i) it is extremely difcult
to attain meta-ethical consensus, and (ii) by reason of the pressing
nature of medico-moral complexes, one is bound by time constraints
and cannot wait for meta-ethical deliberation and consensus. Sufce it
to say that a sound knowledge of moral theories and principles (upon
which they are based) as well as meta-ethics and descriptive ethics can
be an invaluable asset in the ethical decision-making process. While
not necessarily utilizing these in open team discussion – this might well
hinder the process and, indeed, intimidate non-philosophically orientated
individuals – they serve as a foundation for the clarication of elusive
concepts and terms.
Ethical analysis involves both the action and the agent. Consequences
and motivation are crucial considerations in moral evaluation.
The Objects of Moral Evaluation
Focus of Moral
Evaluation
Acts
Agents
Characteristics of the Act Itself:
Can be universalized (Kant)
Does not violate rights (rights theories)
Conforms to God’s commandments?
Consequences:
For the individual (ethical egoism)
For everyone (utilitarianism)
Intentions:
Done for the sake of duty (Kant)
Done because God wills it?
Character:
Promotes human ourishing
(virtue ethics)

Making Ethical Choices
12
Making Ethical Choices
13
Dening Ethical Decisions
Ethical decisions are derived from three basic elements: rst, they
are the result of the rational and judicious analysis of all the pertinent
considerations such that another group of rational individuals considering
the same circumstances would most likely reach the chosen alternative.
Second, they are such that most, if not all, of the affected individuals
could live with them on their consciences. Third, ethical decisions
should adhere to universal moral principles, such as respect for persons
and autonomy, benecence, non-malecence, and justice, rather than
simply appeal to intuitions or personal opinions.
It would be folly to suggest that the team approach would somehow
ensure an ‘absolutely correct’ decision – if such a thing even exists.22
professionals and to specic lay persons, for example the patient (or his/
her alternative decision-maker if this is necessary) and his/her immediate
family, as well as potentially to ‘passive participants’ – citizens from
the general public.23 The procedure should not be contingent upon all
active participants possessing a certain degree of intellectual or medical
knowledge. Otherwise, some legitimate participants would be excluded
from the process, and others would feel daunted and burdened. Everyone
should be able to easily understand, appreciate and respect the process
through which the decision was made.
An Ethical Choice
Adheres to moral principles
Most likely what other reasonable
people ould choose
What stakeholders could live with
on their consciences
Congruent with patient’s values,
beliefs and preferences
Does not degrade or dehumanize
anyone
However, a methodological
decision-making process
attempts to offer a decision
that is the most appropriate
considering all relevant
factors and with the least
inuence from biases
and ignorance in a given
time period for a specic
society.
As opposed to being
able to rationally justify a
particular moral position,
having a ‘rationale’ simply
means that one is able to
offer a consistent set of
(personal) reasons for holding a certain position. The beholder would not
have necessarily considered and addressed the other options or legitimate
sources of morality. From this denition, then, the Ku Klux Klan could
readily provide a rationale for their ‘philosophy’, that is, a consistent
and elaborate set of reasons as derived from certain presuppositions
(premises that most reasonable persons might call biased and prejudicial
in nature).
A morally sound ethical decision-making process must take
into consideration the magnitude of the ramications of its deliberation
through both the audience that is required for active reection, as well
as the audience that it frequently attracts. In other words, it should be
readily accessible, intellectually, to ‘active participants’ – health care

Making Ethical Choices
14
Making Ethical Choices
15
Ethical Dilemmas
At the heart of ethical quandaries is a set of value choices about
which there are deep concerns, disagreements, ambiguity, and uncertainty.
What actually constitutes ethical dilemmas is the fact that it is difcult
to perceive clear or distinct resolutions, and when the general principles
upon which one would usually appeal offer no assistance or, indeed, appear
to contradict one another.24,25 One is faced with at least two alternative
choices, usually the result of conicting ethical principles and interests,
none of which appears to be a satisfactory solution to the problem.26 It
is also likely that all of the alternatives being considered might appear
equally appealing. Furthermore, ethical dilemmas may be perceived as
involving conicts and tensions arising from interrelationships.27
Ethical Consensus
The phenomenon of ethical consensus in health care quandaries
is exceedingly complex, and it is beyond the scope of this handbook
to undertake an analysis of its complicated philosophical arguments.
According to the Oxford Dictionary, there are two basic denitions of
‘consensus’. One denition of ‘consensus’ is ‘unanimity’. Considering
the legitimate plurality of moral sources, and the argument that it
would be morally reprehensible to expect a dissenter to go against
his fundamental values and principles28, ‘unanimity’ is perceived as
being too restrictive, idealistic, and impractical an approach in moral
deliberation (especially in clinical practice and its morally and culturally
diverse environment).29
The position that this handbook takes is concordant with the second
denition of ‘consensus’ which relates to the general or collective
agreement of opinion. It is the judgement arrived at by most, if not all,
legitimate members. This leaves room for dissenters to remain loyal to
the team while allowing the decision to progress (or to excuse themselves
if the disagreement is hopelessly irreconcilable while maintaining
condentiality). This is not the same sentiment as a ‘democratic vote’ in
which the dissenters are not co-opted in loyalty to the decision.
In reaching consensus at the bedside, it is important that should
front line health care providers somehow inuence the operational
policies and procedures of the institution. This sentiment increases the
probability for consensus through mutual moral agreements in a shared
corporate culture. An atmosphere that fosters disgruntled, fatalistic and
insecure employees cannot be conducive to the effective resolution of
very sensitive issues nor to the success of the institution.
In this process, dissenters can perceive, appreciate, and applaud
the sincerity and thoughtfulness of the rest of the members of the team,
noting that the decision was attained with good conscience and utilizing
sound ethical principles. It is crucial to remember that what is important
is not compromise or consensus so much as reective convergence
towards consensus, which is sufciently open, forthright, and candid so
that dissenters can, at a minimum, appreciate its logic and wisdom, if not
go along with it.
This process of moral reasoning and its inherent propensity toward
general moral agreement and consensus also makes it easier for the
dissident to respectfully remain loyal to his/her team’s choice. He/she, as
an active participant in the procedure, should have, at a minimum, a respect
for the impartiality of the process and its noble aspirations. Otherwise,
An Ethical Dilemma
A perplexing situation with
ambiguities and uncertainties
Difcult to prioritize competing/
conicting values/interests
No clear (appealing) alternatives
At least two equally appealing
alternatives

Making Ethical Choices
16
Making Ethical Choices
17
he/she retires from the team while maintaining condentiality. The adult
competent patient’s nal decision carries the day, in the sense that should
this be irreconcilable with the rest of the team’s choice of action, then
the patient has the prerogative to veto any proposed course of action
and to consult another clinician/health care facility. The treatment team
honours such a right to refuse treatment. Under special circumstances,
however, such a right may be restricted.30
Modern societies are culturally diverse. However, individuals and
groups share many things in common, for example, general lifestyle and
a basic moral conviction. According to Kurt Bayertz (1994) “This may or
may not lead to universal and comprehensive consensus, but it frequently
results in a network of “moral family resemblances” among individuals
and groups: a “patchwork” of local dissent and consensus.”31 Consensus,
then, may not be as difcult to achieve as is often presented. Generally,
some relative agreements (and disagreements) exist, and consensus
might be enhanced by the employment of impartial moral reasoning,
and by focusing on building through the threads of agreements, rather
than to attempt to resolve entrenched and unyielding disagreements, for
example, by emphasizing differences in legitimate moral sources.
The decision arrived at should then be a reection of an active and
collective process. Bayertz wisely argues that “Consensus has a claim
to moral authority only when it is the result of a rational communicative
process aimed at intersubjective understanding and a just balancing
of interests.”32 Consensus is usually forthcoming through a process of
moral reasoning, and this is augmented in an atmosphere wherein team
members pay serious attention to one another’s moral position with
respect, tolerance, honesty and sensitivity.
Moral reasoning, then, is perceived as tending toward agreement
rather than disagreement amongst a group of morally sensitive and
rational individuals. Non-reective (that is, intuitive) opinions are voiced,
and the individual is respectfully prompted to scrutinize these in order
of the discussion, and the generally common goal – the welfare of the
patient.
It is important to remember that compared with true consensus,
‘ignorant consensus’ is usually relatively easy to achieve. Employees
are either intimidated and coerced, if not compelled, to acquiesce to tacit
inter and intra-disciplinary and intra-institutional agendas, expectations,
and peculiarities, or they may do so sincerely believing that the position
held by someone in authority (for example a discipline director or
administrator) must possess ‘validity’ (that is, a rationale). This might
be quite adequate for individuals ignorant of ethical deliberation – thus
committing the fallacy of appealing to pseudo-authority.
The ‘impartial facilitator’ (usually the Bioethicist) in the decision-
making process would serve to ensure that all legitimate interests are
duly considered, and fallacies are not committed (in part through rigorous
argumentation). Loyalty to one’s employer and institution is certainly a
very important consideration and, indeed, obligation. However, such a
responsibility is not without qualication, and it is possible to argue that
the duty to rationally seek a morally correct decision for one’s patients
trumps this obligation.
Moral Consensus
General or collective agreement
of opinion by most if not all team
members
NOT unanimity (too restrictive,
impractical and unrealistic)
to achieve greater insight
into the particular position
held. It is possible to argue
that this rational discourse
serves to accentuate
common moral threads
of agreement rather than
disagreement, by virtue of
the perceived impartiality of
the process, the rationality

Making Ethical Choices
18
Making Ethical Choices
19
The Team
The team consists of the patient,33 representation from his/her
signicant others34 and a representation from each health care discipline
that is directly responsible for the care of the patient, for example, the
attending doctor, the primary nurse, the social worker, occupational
therapist, and physiotherapist.
Additionally, consultation from a psychiatrist, should there be any
questions pertaining to the mental status or competency of the patient,
should be available. In view of the deciency in the training of health
care professionals in ethical theory and analytical skills, it is highly
desirable that at least one member of the team demonstrates reasonable
prociency in these areas. Arguably, the Bioethicist is best suited to
reconcile the conicts of pertinent interests/principles and a plurality of
legitimate considerations.
It is not uncommon to nd that health care professionals experience
‘moral distress’ as a result of the traditional autocratic decision-making
process or, indeed, from a sole decision-making approach. Jameton
(1984) describes ‘moral distress’ as a state of psychological distress
experienced by the health care provider (most often the nurse) who
makes a moral decision concerning the care of a patient in his/her
care, but is unable to implement this decision by reason of institutional
constraints.35 This often results in feelings of moral outrage, rejection,
and disillusionment, which can have adverse effects on the health of
very dedicated and caring health care professionals and their ability to
function optimally. Consequently, the quality of care and treatment to
patients deteriorates and, indeed, the general efciency of the institution
is reduced (for example, through staff sick leave/absenteeism, and
prolongation of patient stay).
Effective Team Deliberation
Professional team support is critical, and multidisciplinary team
members are required to suspend decisions during the initial stages
of the process. Everyone must work within the competency of his
profession and capacity to engender a comfortable atmosphere of care
and commitment to the expeditious resolution of the perceived problem
and a return to a state of equilibrium in the patient-team relationship.
The distress that arises from the complex should not be trivialized or
marginalized.
Goal setting is extremely important for the team. Objectives,
specically directed at the welfare of the patient (as perceived by himself/
herself, providing that he/she is a mentally competent adult) ought to
be elucidated. Clarication of the objectives are important so that each
team/committee member can possess a rm grasp of the goals that he/
she is striving toward, and to commit himself/herself to this task at hand.
This saves time, money, and confusion.
Team
Patient (or substitute decision
maker/signicant other), attending
doctor, nurse, social worker, OT,
other health care professionals and
invited persons
Engender a comfortable atmosphere
of are and commitment to the just,
fair and expeditious resolution of
the dilemma.
Team members should suspend
decisions during initial stages of the
process.
During the entire
collective process, the group
should be well focused
on the subject matter –
sidetracking and defocusing
should be minimized. Time
constraints are often crucial
considerations in clinical
practice: rst, because a
critical decision must be
reached very urgently; second, in times of shortages of nance, it would
be prudent to use work time responsibly; and third, defocusing and
sidetracking can convey the message that the matter at hand is trivial
and unimportant.
It is important to remember that most groups have their prima
donnas, a self-elected ofciator who enjoys being the spokesperson, if
not the leader.36 In the multidisciplinary team process for ethical decision-
making, such a destructive activity must be avoided. With respect to the
process of effective discourse, Bruce Ackerman (1989) argues that one
should exercise “conversational restraint.”37 It is highly desirable to avoid
discussions concerning “ultimate truths”38 and to direct the discourse
toward more pragmatic considerations – the pertinent, particular
aspects of the situation being discussed by the team. It is much wiser to
emphasize agreements rather than to quibble, sometimes endlessly, over

Making Ethical Choices
20
Making Ethical Choices
21
irreconcilable disagreements. Such an approach creates a psychological
atmosphere that is much more conducive to arriving at common and
shared social values that everyone could live with – to consensus.
Furthermore, it is important for each person to feel personally
involved and his/her input as being very valuable in the proceedings.
Members ought to feel satised with their input and not inadequate.
In determining the goals and tasks at hand, one should ensure that the
situation is approached very positively and enthusiastically, and the
discussion should be engaging, exible/compromising, and creative.
These characteristics tend to foster an environment wherein mutual
trust, support, and respect are cultivated by team members. This impetus
toward sharing, along with respecting and understanding others, often
leads to a cohesion – a sense of unity in the team. Hostilities are kept to
a minimum, because the conict is being dealt with constructively and
respectfully.
It is common practice that a body of professionals often shares a
set of linguistic terms and expressions that are usually peculiar to its
members, and this is especially apparent in medical practice. This has
at least two major disadvantages. First, it creates an air of knowledge
exclusiveness and an accompanying atmosphere of intimidation and
pre-eminence in the team. Such biases are outrageous – from the very
beginning, mutual respect should be fostered. The focus of the decision-
making process involves an ethical and not a clinical basis (granted that
there is an important clinical component to the discussion) and, as argued
earlier, no team member can reasonably lay a claim to moral superiority.39
Indeed, it is the values and cherished goals of the patient around which
everyone, especially the lay person, could appreciate and comprehend.
Professional team support is crucial – mutual trust, support, and
respect are vital. In particular, respect and sensitivity to one another’s
moral positions form essential facets of the process.
Foster an atmosphere of personal
involvement with valuable input.
Approach situation positively and
enthusiastically.
Meeting should be well focussed
- sidetracking and defocusing should
be minimized through effective
facilitation.
The discourse, in style, expression
and terminology should be such that
everyone, especially the lay person,
could appreciate and comprehend.
the discourse is generally
centred.
Second, throughout
the ethical decision-making
process, it is very important
to remember that effective
and meaningful dialogue
is only possible when
everyone involved has a
reasonable and adequate
understanding of the actual
discussion. Consequently,
the discourse, in style,
expression and terminology
should be such that
Do not trivialize/marginalize what is
at stake.
Goal/objective setting - reinforces
commitment, prevents confusion
and saves time and resources.
Each team member acts according
to his/her professional competency.

Making Ethical Choices
22
Making Ethical Choices
23
Pitfalls to Avoid
It is possible for health care professionals to respond in one of
four basic ways to ethical dilemmas in clinical practice. ‘Professional
ignorance/uncertainty’, ‘moral intuitive’, and ‘preferred source of
morality’, are the commonest responses. A succinct discussion of each of
these responses will be undertaken in order to determine its advantages
and impediments. The position taken here is that the further our society
evolves from the traditional paternalistic model in medicine toward a
more public and ‘democratic’ (that is, a collective and collaborative)
approach, the greater the thrust toward shared responsibility and
accountability and, hence, an analytical decision-making process. Life
is dynamic and, undoubtedly, held sentiments are very important. It is
crucial to remember that, in a constantly evolving world, an impartial
discerning process of ‘thinking through’ held sentiments enhances and
up-dates one’s moral position.
(i) Professional Ignorance/Uncertainty.
A lack of ethical knowledge, analytical and facilitatory skills, as
well as a lack in motivation to seek appropriate resources for assistance
and guidance, may lead some health care professionals to either trivialize
the ethical problem, with the misperception that it would spontaneously
resolve itself in time, or shift the focus from a moral (value) perspective
to other aspects of patient care, for example, clinical or legal, and
resolutions are thence sought through these approaches. Inappropriate and
unjust consequences result – the patient and other staff members could
suffer unnecessary and prolonged emotional distress and processes. And,
the patient might well nd himself/herself being prematurely discharged
from the care of the clinician and/or facility, because of the inability to
effectively and adequately manage the perplexing situation.
(ii) Moral intuitive approach.
Moral intuitions are perceived as immediate and spontaneous
sentiments. They are non-reective, and all pervasive in the daily
activities of most individuals, that is, moral intuitions are practical and
action-guiding, especially when there is little or no time or, indeed,
desire for rational scrutiny. They tend to establish a prima facie case
for an evaluative situation being as it is intuited, that is, without any
rational inquiry, and this can be fraught with prejudicial propensities
and misleading. Moral intuitions, then, are fallible – they are vulnerable
to arriving at rationally unjustiable conclusions through, for example,
misperceptions and a morally prejudiced upbringing.
(iii) Imposition of a Preferred Source of Morality.
This response to a moral dilemma means that the health care provider
utilizes what he perceives to be an adequate justication for making an
ethical choice, based solely on a personally preferred source, either
because of an ignorance of other legitimate considerations, or due to a
dogmatic and rigid attitude. It can occur in both sole person decision-
making as well as in environment-specic decision-making. There is a
plurality of legitimate ethical theories or sources of morality, and in this
approach decisions are the result of a staunch and obdurate afnity for
a specic perspective, for instance utilitarianism or, quite commonly, a
particular religious belief system.
(iv) The Analytical Approach: Bioethical Model.
It is necessary to use Bioethics in order to provide rationally
defensible solutions (ensuring clarity, coherence, consistency and
adequacy) to perplexing situations and quandaries effectively.40 Unlike
other very common ‘methodologies’ that are used to obtain answers, for
example, ‘intuition’ and ‘personal preference’ approaches, biomedical
ethics offers a systematic process that attempts to sift out biases,
prejudices, unjustiable opinions, and irrelevance, and to ensure that the
decision secured is the most morally weighted and rationally justied
under the given circumstances.
Pitfalls to Avoid
Ignoring/Marginalizing value issues
Clinicalizing value issues
Imposing personally preferred
morailty
Using purely intuitive responses
(exept perhaps in emergencies)

Making Ethical Choices
24
Making Ethical Choices
25
Fallacies
It is certainly beyond this handbook to provide instruction on
critical thinking and argumentation skills. It is very important, though,
to note that reasoning is primarily based on sound argumentation.
A valid argument is one where (i) the premises possess truth-value
and are rationally acceptable, (ii) the premises logically support the
conclusion, and (iii) only considerations relevant both to the justication
and rejection of the conclusion are taken into account. Here is a list of
common fallacies to be mindful of and hopefully avoid41:
Fallacy of Ambiguity: This occurs when an expression can be understood
in at least two distinct ways, and there is no clear way to tell how
it was meant within the context of an argument. Ambiguity can be
either syntactic or semantic (see below).
Fallacy of Appeal to Ignorance: This occurs when either a conclusion
is said to be correct merely because there is no known evidence to
establish that it is not, or when a conclusion is said to be incorrect
because there is no known evidence to establish that it is correct. In
both cases, the lack of evidence is appealed to in support of some
conclusion.
Fallacy of Appeal to Pseudo-Authority: This occurs when, in supplying
evidence for a conclusion, either (i) a recognized authority in one
eld is cited as providing evidence in another area, or (ii) when
someone or something is assumed to be authoritative when in fact it
is highly controversial and questionable.
Fallacy of Appeal to Pity: This occurs to the extent that, instead of
giving evidence to support a conclusion, the person appeals merely
to the emotions of the receiver(s) to accept the conclusion.
Fallacy of Equivocation: This occurs when the conclusion of an
argument depends on the meaning of a single ambiguous expression
shifting between two or more denitions, within the argument.
Fallacy of Fake Precision: This occurs when a claim purports to have
(empirical or statistical) precision that is practically impossible yet
is still used as evidence.
Fallacy of Neglect of Relevant Evidence: This occurs when pertinent,
but unfavourable, considerations to an argument or conclusion are
ignored or marginalized.
Semantic Ambiguity: This occurs when a term has two or more distinct
meanings and the context in which that expression is used does not
clarify its use.
Syntactical Ambiguity: This occurs when different interpretations of a
sentence result from unclear grammatical structure.
Fallacy of Vagueness: This occurs when a vague premise or conclusion
is advanced in an arbitrarily (and deceptively) precise way while
attempting to maintain an illusion of a broad meaning.
Fallacy of Ad Hominem: This occurs when an attempt is made to
discredit an argument by attacking the character of the presenter of
the argument instead of addressing the argument itself.
Fallacy of Poisoning the Well: This occurs when a person attempts to
discredit an argument by including irrelevant information instead of
focusing on the argument itself
Fallacy of Begging the Question: This occurs when the conclusion of an
argument is simply a restatement, usually in a different vocabulary
or form, of one of the premises. It does not, therefore, substantiate
or justify anything.
Fallacy of Confusing Necessary and Sufcient Conditions: This
occurs when a necessary condition is presented as a sufcient one in
supporting some conclusion.
Fallacy of Deceptive Alternatives: This occurs when a premise
incorrectly suggests, explicitly or implicitly, that the alternatives
mentioned are mutually exclusive or exhaustive of all possible
alternatives relevant to the conclusion. This creates a false dilemma
by limiting viable options.
Fallacy of Inconsistency Claims: This occurs when an argument
contains contradictory claims – a person makes a certain claim at
one time and its contradiction at another without providing reasons
for this change of position.
Is-Ought Fallacy: This occurs when a conclusion asserting what should
be the case is based solely on considerations of what is or has been
the case. For example, to derive moral (value conclusions) directly
from empirical data without further analysis is highly suspect.
Fallacy of Red Herring: This occurs when an attempt to discredit an
argument is made by including considerations that, while broadly
related to the original argument, are redundant to the specic claims
of that argument.
Fallacy of Simple Correlation: This occurs when it is assumed that a
mere correlation between two phenomena is sufcient to establish a

Making Ethical Choices
26
Making Ethical Choices
27
causal relation between them.
Fallacy of Slippery Slope: This occurs when it is asserted, without
adequate evidence or justication, that one event will necessarily
lead to another, and that this second will necessarily lead to yet
another in a chain of events until some nal (usually very unpleasant)
situation is brought about.
Straw Man Fallacy: This occurs when an attempt is made to discredit
an argument by recasting it in a weak, exaggerated or foolish way
not intended by the arguer and, then, attacking that refashioned
argument as if it were the original one.
Tu Quoque Fallacy: This occurs when there is an attempt to defend
an argument against attack by suggesting that the critic has done
something very similar, if not the same thing – as if “two wrongs
make a right.”
Wishful Thinking Fallacy: This occurs when desiring or believing that
some claim is correct or incorrect is actually substituted for evidence
for that claim without adequate justication.
Personal Values
It is misleading to believe that there is a denite distinction between
private and professional morality. Ethical decisions made at work,
home, or in church reect one’s character, convictions, and conscience.
The personal values of all team members play an enormous part in the
analysis and resolution of an ethical dilemma. It is possible to argue
that because the patient has most at stake in the situation – it is his/her
physical and emotional health, welfare, and even perhaps death that will
be affected by the consequences of the decisions made – his/her values,
wishes, and preferences should rightly form a crucial aspect of the
ethical decision-making process. However, it is extremely important to
remember that while a patient has a right to seek treatment for a perceived
ailment as well as a right to veto or refuse a particular proposed course of
treatment, he/she cannot mandate treatment.42
A patient’s autonomy is usually reective of his/her desires, opinions
and values. Undeniably, respect for patient autonomy is a cardinal
biomedical principle. It asserts that persons should be completely free
(from coercion or compulsion) to act in accordance with their personal
beliefs, thoughts, desires, and values. Although it is a prima facie moral
principle, there are circumstances under which respect for this principle
may justiably be temporarily suspended and overridden by competing
moral obligations. Therefore, respect for a patient’s autonomy is not an
absolute duty incumbent upon a clinician or facility. The Mental Health
Act acknowledges this consideration in the case of imminent danger to
oneself and/or to others.43
There are times when a patient’s needs conict with his/her desires.
A typical example is the patient who requests and insists upon receiving
a prescription for antibiotics for his/her sore throat when, in fact, he/she
has a viral infection. Not only are the antibiotics not indicated, but they
might well be harmful to him/her, with short term adverse effects, as
well as harmful long-term consequences, for example, drug resistance.
And, requesting and even requiring a scarce resource for which no
funds are available is an example of a morally justiable restriction on
a person’s autonomy. Clearly, the clinician has his professional integrity
and autonomy to respect and, in these situations, the decision to honour
these and to override the patient’s autonomy would be considered
ethically justiable and appropriate. Despite the fact that it is the patient
who has most at stake in the situation, no team member should be
coerced or compelled to participate in any activity that clearly offends,
or is diametrically opposed to, his/her personal and professional value

Making Ethical Choices
28
Making Ethical Choices
29
system.
Some clinicians perceive a tension between the notion that it is
the physician who could possibly be held legally accountable (as the
person who is responsible for the overall treatment of the patient) and
the argument for the inclusion and equal weighting/consideration of
the opinion and values of other legitimate members of the health care
team. With the shifting paradigms in health care delivery, for example,
with increased front-line health care professional empowerment and a
focus on a multidisciplinary team approach, it would be just and fair
that legal accountability and responsibility accompany the increased
shared professional and moral rights and obligations to patients. Such
an equitable distribution of responsibility with respect to the ethical
identication and resolution of ethical dilemmas is especially evident
if each member of the team is granted full participation membership.
In congruence with this diffusive responsibility, as argued earlier, there
appears to be a judicial shift toward holding health care institutions (rather
than individual clinicians) more and more accountable and responsible
for the overall care of the patient.
Ethical decision-making is a collective and collaborative process.
However, following the deliberation, it is perhaps the physician, as the
‘team leader’ in clinical practice, who ensures that the chosen action is
implemented. In this sense, the physician’s position as the primary person
responsible for the overall treatment of the patient (within the facility and
in the everyday operation of treatment) would not be affected, and his
appreciation of the inclusion of other legitimate members of the health
care team in an effort to effect a morally justiable and expeditious
course of action under the specic circumstances, would be nothing less
than commendable.
Furthermore, patients have an obligation to their clinicians to
consider the alternatives seriously, including identiable expected
consequences of each, as well as priorities set by their clinicians. They
have a responsibility to take seriously the advice of the professional
whose expertise they seek. Of course, they have a right to second/
alternative opinions. However, once agreed to engage in therapy with
a clinician, a tacit contract is initiated, and both parties should respect
each other’s duties and obligations. It has been argued that the clinician
may not terminate the clinician-patient relationship unless: the treatment
modality is completed by its own nature; the patient terminates the
relationship; there is a mutual agreement to terminate the relationship
(for whatever reasons); and the clinician informs the patient of his intent
to terminate care sufciently ahead of time, thus allowing him time to
secure another clinician.44
It is important to remember that a physician cannot abandon a
patient. This may occur when the physician severs the relationship with a
patient without reasonable notice when the need for treatment exists and
is expected, when the physician fails to notify the patient of impending
absences, fails to provide reasonable care and treatments, or any other
improper withdrawal from the physician-patient relationship.45
Proper Termination of a Relationship
Patient is given reasonable notice
Patient is assisted in nding another clinician
Appropriate records and information are
provided to the new clinician as requested by the
patient
Personal Values
It’s a myth to think that one
can differntiate between “public
morality” and “private morality”
Moral decisions at work, home and
at church seat in one’s conscience
“The softest pillow to sleep on is a
clear conscience”

Making Ethical Choices
30
Making Ethical Choices
31
Moral Reasoning
Moral reasoning, that is, assessing arguments to determine goodness/
badness, rightness/wrongness, fairness/unfairness, can be very complex.
Our sense of what is moral is often fraught with emotions and perhaps
unreective opinions. This is why it is especially important to critically
evaluate value-laden situations and to use rigorous moral reasoning skills
in arriving at moral judgements. While it is beyond the purpose of this
handbook to undertake an analysis of such skills, it is noteworthy that
moral maturity is a crucial element in moral reasoning.46 This may be
described as characteristics exemplied by a morally mature, reasonable
person. These include the following:
i) Justication by appeal to principles – it is important not to simply
appeal to personal beliefs and opinions but instead to some general
justicatory principle.
ii) Independence of judgement – we need to recognise that we must
accept personal responsibility for the moral judgements that we
make or espouse, rather than to hold moral judgements because of
someone else’s authority.
iii) Consistency – we should be consistent in the moral positions that we
hold – between different moral issues and between our actions and
judgements.
iv) Awareness of complexity – we should acknowledge the complexity
of moral issues and indeed principles. What, for example, do the
moral maxims “respect all life” or “be fair” really mean? As Aristotle
warned about ethics, “Don’t expect any more precision than the
subject matter will allow.”
v) Recognition of our fallibility as human beings – we need to recognise
that there is always the potential for personal biases and prejudices,
albeit non-malicious. The morally mature person will be open to the
fact that further reection, dialogue and discourse may lead us to
modify our positions.
vi) Factual element – it is important to realise that we need to seriously
consider the facts that pertain to the situation. In health care, these
would include investigative and diagnostic information. Indeed, it
might become necessary to seek the judgement of ‘experts’ in the
factual realm; however, it is crucial to remember that the moral
domain, while incorporating facts (and probabilities), is a separate
entity.
vii) Understanding, respect and tolerance – moral judgements in health
care invariably involve moral diversity and sensitive matters that
impact all stakeholders. Mutual respect and tolerance are therefore
extremely important, even when we disagree with the values, beliefs
and judgements of others. Moral reasoning is to a great extent an
activity that includes learning from each other.
viii) Generalization of moral judgements – one of the litmus tests for
moral judgements is that what we consider right (or wrong) for a
person under certain circumstances must also be right (or wrong) for
others under relevantly similar circumstances.

Making Ethical Choices
32
Making Ethical Choices
33
The Law
It is very important to consider what the legal components of the
case might be. The laws of the land should be adhered to. Laws attempt
to reect what is generally considered morally acceptable in a particular
society. This is not to suggest that all laws are necessarily moral, and we
have seen the enactment and implementation of morally repugnant laws
over the centuries.47 Indeed, it could be argued that the law is constantly
trying to keep apace with morality. Casuistry, through precedent-setting
medico-legal cases, can provide effective and invaluable direction with
respect to dynamic societal values and legal constraints.48
It is of paramount importance of health care professionals and
administrators to consider their legal duties and obligations to all
stakeholders. For example:
1. The duty to attend
2. The duty to consult and refer
3. The duty to diagnose
4. The duty to inform the patient
5. The duty to obtain patient’s consent to treatment
6. The duty to provide treatment
7. The duty to use care
8. The duty to instruct the patient
9. The duty to maintain condentiality
10. The duty to take responsibility for associates and staff
11. The duty to keep medical records
12. The duty to give evidence
13. The duty to be licensed
Hospital liability for the care of a patient generally arises from a
breach of contract or by an act of negligence (by its staff and/or through
defective equipment). Claims may also arise from the hospital’s selection,
instruction, and supervision of staff, as well as the care and treatment
provided. The expectation is that patients will be cared for by skilled
persons who will attend and treat them.49, 50
Professional Codes of Ethics
Professional codes of ethics, as a set of general guidelines, are
necessary in providing certain parameters in the patient-health care
professional relationship and interaction. They generally sufce
in fullling this purpose. However, there are several signicant
disadvantages that render them ethically inadequate. First, professional
ethics usually have an underlying set of presuppositions that are,
themselves, suspect under closer scrutiny. For example, the Hippocratic
Oath emphatically forbids euthanasia and abortion without offering any
justication whatsoever for these categorical prohibitions.
Second, professional codes of ethics tend to be profession-specic,
for example, a code for doctors, one for nurses, another for psychologists,
and so on. Generally, each professional code seeks to promote the
welfare of its membership, and it is possible to have conicts between the
various codes of professionals who care for the same patient. A corollary
is that the primary focus of professional codes of ethics is toward their
members, with patients’ welfare as secondary interest. Better-informed
patients in today’s society are demanding that patients’ values (rather
than professional values) play a predominant role in professional codes
of ethics.
Third, a list of a professional code of ethics cannot provide solutions
for the quantity of moral dilemmas that are pervasive and inherent in the
complex grey areas of real life situations, involving unique individuals
and circumstances, for instance, when there are conict of interests.51
Generally, professional codes of ethics are inadequate in directing a
Common Areas of Malpractice
Improper diagnosis of the patient
Improper treatment of the patient
Failure to protect the patient from self harm
Sexual exploitation of the patient by therapist
Regulatory improprieties (improper informed consent,
intrusion of patients’ rights, condentiality issues, and
improper commitment procedurres)

Making Ethical Choices
34
Making Ethical Choices
35
clinician’s actions in complicated situations or in the effective and ethically
justiable means of resolving a moral dilemma. These codes need to be
exible in order to ‘prioritize’ principles when they conict, and they
need to be binding upon the professional in order to be meaningful and
practical. What ought to be borne in mind, is that, at its best, professional
codes provide a rough guideline for a specic group of professionals
within the context of, and relevant to, that particular profession. In this
regard, it is possible to nd the professional code of ethics from one
professional organization conicting with that of another, and with
each adamantly adhering to its own professional code, no resolution is
forthcoming. Additionally, professional codes of ethics generally express
the values of the profession and not the values of any particular patient or
of society as a whole. Not unlike the law, professional codes of ethics are
certainly not immune from acts that constitute moral indignation.52
Institution’s Mission, Values, Policies &
Practices
“Will not the knowledge of [the good], then have a great
inuence on life? Shall we not, like archers who have a
mark to aim at, be more likely to hit upon what is right?”
(Aristotle)53
Institutional policies and practices are sometimes developed with
the intention of protecting against legal action, and are only too often
followed in a ritualistic way. It is crucial that policies and practices, and
indeed, those who implement them, foster a climate of open dialogue and
collaboration. In particular, competent patients should never feel that they
would be abandoned or isolated because of their decisions. Advocating
for patients involves supporting them in the decisions that they make,
even when members of staff disagree with their choices. The institution
should have an easily accessible and fair mechanism for patients and
staff to resolve disagreements and conicts when they occur.
Health care administration is a very complex phenomenon, and it is
not the purpose of this handbook to offer an exposition and analysis of
duties and responsibilities (moral, legal and social) that arise from sound
business or organizational ethics. However, it is important to appreciate
that relationships within organizational structures are generally based on
intrainstitutional socialization to values and norms, and ideal employees
are viewed as those who are congenial with its operations in every way.54
Irrespective of the employees’ response – either rejection of values and
norms, or engagement in only chosen values and norms, or conformity
to all values and norms – the fact remains that an institution’s mission,
policies and practices represent extremely powerful constraints for health
care providers, the employees of the institution.
From an ethical perspective, it is crucial to engage diverse moral
perspectives in the development of pivotal values and philosophies, rather
than to simply attempt to align employees conduct with organizational
norms and standards. Rigid adherence and conformity can sometimes
override realistic appraisal of alternative perspectives through
“groupthink”, thereby hindering growth and success.55 This begs the
pressing question concerning how administrators and managers respond
to the inherent ambiguities and uncertainties in the ethical terrain of
institutional norms, values and customs.
It is extremely important to remember that institutional values,
Laws & Professional Codes of
Ethics
Laws aren’t necessarily moral; often
too broad
Codes aren’t necessarily moral; very
general; little direction in prioritizing
conicts of principles or interests;
profession-specic; primarily serves
interests of profession

Making Ethical Choices
36
Making Ethical Choices
37
especially as they pertain to health care, should be viewed as also having
intrinsic worth (such as justice, honesty, and respect for human dignity),
rather than simply primarily serving some utility. In a context of potential
for divided loyalties, it is vital to have a mechanism that would ensure
a just balancing of legitimate interests; for instance, the zealous pursuit
of efcacy and revenue must be tempered with honouring social and
moral responsibility to all stakeholders. Most of the moral principles
that govern the conduct of health care professionals will also apply to
the health care institution. In addition, general moral principles (such
as honesty, reliability, integrity, justice, and common decency) form the
bedrock for just and fair dealings with all stakeholders.
Frequently, an institution’s ‘mission’ had been developed without
adequate input and involvement from front line health care providers, yet
they often serve as very decisive considerations in the courses of action
that are available to health care professionals. Sometimes, of course,
ethical difculties may themselves arise from conicts between the
institution’s mission and interests and the professional’s perceived duties
and obligations to a patient and even patients in general. These powerful
inuences do affect one’s ability to act ethically, and it is crucial for
health care professionals to consistently maintain duciary integrity with
their patients.
Ethical Principles & Guidelines
Fiduciary Relationship
The clinician-patient relationship is rooted in a moral foundation. In
other words, it is based on the duciary understanding – trust, good faith,
and condence – that the clinician and institution will consistently pursue
and safeguard the patient’s well-being and best interest. Clinicians acting
as duciaries are not permitted to use the professional relationship solely
for their personal benet, and they should deliberate and act extremely
carefully in matters relating to “double agency” (to simultaneously
serve the patient and an agency, institution or society.56 Several moral
principles and duties govern this advocacy and duciary alliance.
1. Ethical Duty to Patients
a. Respect for Persons and Autonomy
Every patient has a right to be treated with respect, dignity, and worth
as a human being. This involves respecting the person’s ‘autonomy’ or the
right and liberty to determine and pursue his/her cherished values, beliefs,
goals and preferences in life. Autonomous persons act: (1) intentionally
(2) with understanding, and (3) without controlling inuences that
determine their action. Responsibilities accompany rights, and patients
are expected to act responsibly in their right to autonomy; for instance,
they must honour the rights of everyone else. Patients have a right to
safety, privacy and condentiality. The law and ethics rest the onus on
the violators of patient autonomy to justify their action with great moral
rigour.
b. Benecence
Health care professionals are bound by the ethical duty and
commitment to actively pursue, promote and protect the welfare, well
being and best interest of their patients. Benecence must also be pursued
in a compassionate, effective and timely manner. Patients’ autonomy and
best interest always comes rst, and patients are strongly encouraged to
make fully informed choices. Invariably the patient has most at stake and
should be incorporated, as best as possible, in pertinent decision-making
processes.
c. Non-malecence
“Primum non nocere” or “above all do no harm.” Health care

Making Ethical Choices
38
Making Ethical Choices
39
professionals are bound by the ethical duty and obligation to not cause,
indirectly or directly, harms or evils to patients. An exception is when
harms are calculated and greater benets are anticipated on a harm-
benet analysis, and when the patient agrees to run the risk of the harms.
An example of such a harm would be the adverse effects of a medication,
investigative or treatment procedure.
d. Justice
Health care professionals are bound by the ethical duty to allocate
and use all health care resources efciently and effectively, with justice
and fairness to all stakeholders, and with full regard for individual worth
and dignity. It is important to remember that health care professionals
are, like administrators and policy makers, gatekeepers to limited health
care resources. Admission criteria should reect acceptable practices
regarding fair access to care and treatment, and therapeutic practices
must carefully balance benet-burden analyses.
2. Ethical Duty to Community/Society/Humanity
Health care professionals and administrators are bound by the
ethical duty and obligation to consider the well being and safety of
others, especially when serious risks or harms are anticipated.57 There
also exists a general responsibility to promote health and happiness and
to ameliorate pain and suffering as a service to humanity. In part, this
can be achieved through the pursuit of insights into, and treatment for,
diseases and disorders through education and research. Research will
always be conducted according to strict ethical codes of conduct.
3. Ethical Duty to Colleagues
Health care professionals have an ethical duty and obligation to
work collaboratively, as a multidisciplinary team, to protect and promote
the health, well being and interest of patients. In so doing, they have a
responsibility to respect the professional competencies, values and moral
convictions of each other. Team allegiance in team decision-making is
also extremely important.
4. Ethical Duty to Employer
Employees should recognize the ethical duty and responsibility
to serve their employer as trustworthy and committed agents,58 acting
consistently with the values and philosophy of the institution, and
promoting the institution’s mission and legitimate interests as required
by their employment (job description) and within the constraints of the
law and sound ethical conduct.
5. Ethical Duty to Employees
Employers have a duty to provide a safe, respectful and pleasant
work environment for their employees. Employees have a right to clear,
coherent and reasonable job description, as well as entitlements to
competitive wages and benets, to meaningful input in situations that
affect their work, and to respectful and constructive feedback with regard
to their performance. Employers also have a responsibility to employees
to provide opportunities for continuous personal and professional growth
and development. Growing and thriving environments excel in honest
and respectful communication and treatment of one another.
6. Ethical Duty to Legitimate Third Parties
There lies an ethical duty and obligation to collaborate with
legitimate third parties such as signicant others, government agencies,
health care institutions, and insurance companies, in an effort to promote
and protect the interests and well-being of our patients in a respectful,
just, efcient and effective manner.
7. Ethical Duty to Oneself & One’s Profession
Health care professionals should realize a moral responsibility for
continuous growth and development in their personal and professional
lives. The health care provider role requires that their conduct reect
moral sensitivity and maturity, mutual respect, professional competency,
sound reasoning and compassion, and that they stay abreast of
developments in the art and science which they practice. In this way,
they can be faithful to their trust – to provide the best possible care and
treatments to patients, to maintain personal and professional integrity,
and to serve their community and mankind.
Ethical Principles
Respect for Persons and Autonomy
Benecence
Non-malecence
Justice

Making Ethical Choices
40
Making Ethical Choices
41
The Virtues
(complement Ethical Principles)
Health care practice includes and transcends the adherence to certain
moral maxims and legal principles. Indeed, the law simply sets the bare
minimum for acceptable practice. Virtue ethics places greater emphasis
on the character than on the actual action of the person. Instead of asking,
for example, “what should I do?” virtue ethics mainly asks “what kind
of person should I be?” According to the Father of Philosophy, Aristotle
(384-322 BC), the character that has assimilated the primary virtues will
consistently deliberate and act morally right.59 Consider, for example,
how cold, distant and inhospitable health care delivery would be in the
absence of care and compassion to a distraught family whose teenage
child recently committed suicide.
Aristotle denes virtue as a habit or disposition of the soul and
involves both feeling and action, and which seeks the mean in all things
relative to us (as the prudent man would dene the mean).60 For example,
a deciency of regard for other people is seen as exploitation, an excess
as deference, while the mean is viewed as respect. Virtues, according to
Aristotle, leads to happiness and human ourishing.
The virtue of self-effacement is the willingness to routinely set
aside differences and considerations that should either not count or be
kept in rightful perspective in the care of the patient. These include
religious differences, personal pecuniary benets, and sexual attraction.
Should the health care professional’s own interests become his primary
focus of attention, albeit unwittingly rather than surreptitiously, it is not
uncommon to nd the patient’s best interests slip away.
The virtue of self-sacrice is the willingness to risk one’s own
interests, within reasonable limits of course, and to make personal
sacrices in the pursuit of the health, best interests, and life of the patient.
Adhering to these virtues would help to place moral reins on the conduct
of clinicians, thereby harnessing the natural inclination to focus on
themselves in favour of the interests of the patient. As the Medical Oath
of Moses Maimonidies states: “Do not allow thirst for prot, ambition
for renown and admiration, to interfere with my profession, for these can
lead astray in the great and noble task of attending to the welfare of Thy
creatures.”
Other associated virtues are compassion, integrity, and justice.
Compassion is the willingness to identify and expeditiously respond to
another person’s suffering and distress. It incorporates and transcends the
virtue of empathy (or feeling for another), and involves the motivation to
decisively act to relieve grief and afiction. Integrity is the willingness
to develop well-calculated ethical and clinical judgements in an effort to
preserve and promote the patient’s best interests. The virtue of justice is
of paramount importance in all aspects of social, economic, and political
life, and health care is no exception. We are faced with the harsh reality
that we have limited resources, and how we allocate these is certainly a
challenge that we all face.
Health care professionals who have internalized these virtues into
their characters and who use universal moral principles as guiding
precepts stand a good likelihood of consistently acting with the best of
motives and using morally justiable means aimed at the most desirable
consequences. It is this noble character that forms the basis, the guarantee
if you will, for the trusting relationship which is crucial to the health care
process.
We ought to remind ourselves that there exists an enormous
imbalance of power in the patient-clinician relationship. The clinician
possesses the expertise that patients require in order to restore their health
and to reduce, if not ameliorate, their pain and suffering. This places the
dominance of power and authority in the hands of the clinician, and he
or she can either use it wisely, for good, or poorly, and bring about great
harms and evils. So much is riding on the good will and integrity of
clinicians in this advocacy and duciary relationship.
The Virtues
(complement ethical principles)
Examples are Integrity, Compassion,
Justice, Self-sacrice and Self-
effacement
“Just like the sight of one sparrow
does not Spring make, so too
one good deed does not a good
character make.”

Making Ethical Choices
42
Making Ethical Choices
43
Ethical Decision-Making Model
“But in order to pave the way for such a sentiment (that is,
one that forms the basis of a moral judgement) and give
a proper discernment of its object, it is often necessary,
we nd, that much reasoning should precede, that nice
distinctions be made, just conclusions drawn, distant
comparisons formed, complicated relations examined, and
general facts xed and ascertained.” David Hume61
The process starts with disequilibrium in the integrity of the milieu.
In practice, a member of the team, the patient or a member of his/
her family, perceives disequilibrium in the milieu – seemingly a dilemma
has arisen. A member of the team is uncertain as to what the next course
of action should be, or someone is unhappy/distressed with a particular
situation, and appropriate help is sought – a concern or complaint is
lodged, ofcially or unofcially. The situation has no clear alternatives,
has far-reaching implications, involves a number of people (directly and
indirectly), and has a perception of unresolvability through an identiable
clinical solution. The specic nature of the problem may or may not be
identied at this point.
The matter is taken to the team for discussion. The lodger of the
concern should be accorded full respect for his/her feelings and opinions.
The situation should be treated with a sense of urgency and with full
condentiality. The primary person who lodged the concern/complaint
should provide a description of the perceived difculty to the team.
Either the team offers a reasonable and ready explanation or solution to
the satisfaction of the individual, or identies the existence of a medico-
ethical dilemma. If the existence of a dilemma is conrmed, then the
team proceeds to the First Stage in the Ethical Decision-Making Process.
Team involvement is a nothing less than a collective and collaborative
process.
Moral Intuition
Brainstorming
Re-examination
of Information
(esp. Values)
Juxtapose with
Values & Prioritize
Stage 1
Stage 2
Stage 3
Stage 5
Stage 4
Stage 6
Stage 7
Stage 8
Stage 9
Perplexing Situation
Inter-disciplinary Team &
Patient Meeting
Problem Resolved
Preventative Strategies
Problem Unresolved
Inter-disciplinary Team
Meeting (include “Impartial
Facilitator” if possible)
Ethical Nature
Duties & Obligations
to all Stakeholders
Nature of
Specic Conict
Critical Analysis -
Viable Alternatives
Resolution Strategies
with Preferential Scale
Action Implementation
Evaluation of Outcome
Preventative Strategies
Gather Information. Identify
Stakeholders, Values and
“Contextual Constraints”
Separate Clinical, Legal &
Ethical (Value) Facets
Clinical/Legal
Nature
Appropriate
Action
Unresolved
Preventative
Strategies
Resolved
Respect for autonomy,
benecence, non-male-
cence, justice.
Consider who, when, and how to implement.
Dilemma resolved? Other problems created?
Need to revisit?
Conict of
principles/
interests
Deontological (prima facie duties)
& teleological - short & long term
consequences.
“Context Constraints”: time,
resources, prof. codes of ethics,
& inst. policies and practices
Making Sound Ethical Choices in Health Care: an Analytical
Decision-Making Model

Making Ethical Choices
44
Making Ethical Choices
45
Stage One: Recognition of Dilemma & Comprehensive
Information Gathering, Including Personal Values and
Contextual Constraints.
Gather as much information as possible and, in so doing, ensure that
nothing relevant gets missed. All judgements should be suspended, and
members ought not to rush to conclusions. Moral intuitions play a great
part at this stage. Brainstorming is very important in order to explore
and generate a wide variety of possibilities and options. Professional and
personal values, opinions, ideas, and feelings are voiced. It is imperative
to foster an atmosphere of mutual trust, respect and co-operation.
Remember that there may be ambiguity, uncertainty and perhaps fear,
anxiety and resentment. Moral judgements made in a professional
capacity would affect one’s conscience, one’s private sphere. Ideally, the
team aims at arriving at consensus in decision, and this is only attainable
when team players are satised that their respective positions have been
heard, appreciated, and critically evaluated in the process, and they have
in front of them a decision that they could live with.
1. DILEMMA
Q: Why is there disequilibrium in the patient-treatment team
relationship or dissension amongst team members with
regard to patient care and treatment?
Q: What is causing the qualm, uneasiness, or apprehension?
Note: Conrm that a dilemma exists. Something is amiss, and the
team doesn’t really know what to do. It probably doesn’t
even know exactly what is the problem. The team perceives
at least two alternatives from which to choose, but cannot
agree on a choice.
2. STAKEHOLDERS
Q: Who are the legitimate stakeholders, and what has each at
stake?
Note: The primary stakeholder is invariably the patient. Other
stakeholders might include signicant others, health care
professionals, the hospital, others (co-patients, society,
insurance company, employer, etc.)
3. PATIENT’S VALUES, WISHES AND PREFERENCES
Q: What are the patient’s values, wishes and preferences?
Note: If the patient is suicidal or homicidal or unable to care for
himself/herself (as dened in the Mental Health Act), then
there is need to honour the duty to rescue and/or protect.
Q: Are there reasons to suggest that the patient may not be
mentally competent to consent to, or refuse, care and
treatments?
Note: The assumption is always that the patient is mentally
competent. If the patient is unable to provide consent or lacks
‘capacity’, then one needs to follow an Advance Directive,
proxy, or Power of Attorney for Personal Care. If none of
these exist, then elect one (in accordance with the Mental
Health Act). It is important to remember that a patient’s
seemingly irrational decision does not, by itself, constitute
incompetence.
Q: Are there rationally justiable reasons why the patient’s
preferences might be overridden?
Note: The onus is always on the health care professional(s) to justify
any overriding of patients’ values, wishes and preferences.
4. TIME
Q: Does this constitute an emergency situation (as dened in the
Mental Health Act), and how much time is there to arrive at a
decision?
Note: If classied as an emergency, then act with prudence to rescue
and protect if unable to secure consent from the patient or
Substitute Decision Maker, and if no Advance Directives
are available. Further deliberation is required after the initial
intervention in order to determine an ethically acceptable
course of action. How might another reasonable clinician/
treatment team act under similar circumstances? Casuistry
can be extremely useful in an emergency situation, because it
provides the team with past precedent-setting cases and their
outcomes.
5. RESOURCES
Q: What are the relevant resources at the team’s disposal?
Note: If the resources (expertise/competency or material) are
inadequate or unavailable resources then a consultation and
perhaps transfer to an appropriate clinician and/or facility
might be necessary.

Making Ethical Choices
46
Making Ethical Choices
47
6. INFORMATION GATHERING
Note: There is a need to have a thorough case description (includes
culture, religion, language, etc); medical and mental illness
(includes history, investigations, severity, prognosis, etc); all
therapeutic alternatives available to manage the condition,
including probabilities of each with its risks and benets,
as well as the ramication of non-intervention. Clarify what
information is factual and what is uncertain/undetermined.
7. PROFESSIONAL CODE OF ETHICS
Q: What guidance, if any, is provided by the applicable code(s)
of ethics?
8. THE LAW
Q: What guidance, if any, does the law provide under these
circumstances?
Note: It’s usually very helpful to have a knowledge of precedent-
setting cases (casuistry)
9. HOSPITAL POLICY & PRACTICES
Q: What are the institution’s current policy and practices in these
situations?
Stage Two: Attempt to Separate the Clinical, Legal and
Ethical Components
Having gathered as much pertinent information as possible, the
team proceeds to identify the nature of the difculty. There are usually
clinical, legal, social, policy and procedural considerations that are
intricately interwoven with the ethical component in medico-moral
dilemmas. Serious attempts should be made to tease these apart, within
reason, in order to ensure clarity of consideration.
Q: What is the legal dimension to the dilemma?
Note: Consider if the law of the land has been, or stands to be,
violated; for example: does the patient meet the criteria for
dangerousness or is seriously vulnerable; has there been
an allegation of child abuse or sexual misconduct; or does
it involve a patient who is impaired to drive a vehicle/y a
plane?62 In medical practice, laws usually have qualifying
phrases that allow for value judgements. Concepts like
‘reasonable’, ‘sufcient’, ‘lawful excuse’, and ‘unwarranted’
are duly considered in courts of laws, “in an effort to give
substance to the moral convictions of reasonable or common-
sense people.”63 This is especially relevant in the discipline
of psychiatry, because of the extensive usage of elusive
and ill-dened terms and concepts. If the dilemma involves
a predominantly legal issue, seek direction from hospital
policy, Risk Manager, or legal counsel, and act with team
consensus ideally.
Q: What is the clinical dimension to the dilemma?
Note: Consider current medico-scientic data as they apply to the
case. It is very important to heed Howard Brody’s caution
that “With an ethical dilemma, we can have all the data in the
world, and we still cannot arrive at an answer until we come
to grips with our values and make some value judgements.”64
If the dilemma involves a predominantly clinical issue,
collaboratively (team and patient and/or Substitute Decision-
Maker) determine the most appropriate course of action.
Consider if you might benet from a medical/psychiatric
consultation. Act with team consensus ideally.65
Q: What is the ethical dimension to the dilemma?
Note: It is important to remember that anything associated with
values – rights and entitlements, duties and obligations, as
well as justice and fairness – are inherently ethical. If the
dilemma involves a predominantly ethical (value) issue,
then progress to Stage Three. Consider a consultation from a
Bioethicist (if available).
Stage Three: Pertinent Ethical Duties & Obligations
Specify the ethical duties and obligations that pertain to the case,
noting how they apply. It is important to remind oneself that it is the
patient who usually has most as stake. Values are only meaningful in a
context of duties and obligations. Pertinent ethical principles include:
(1) Respect for autonomy – to respect the individual’s right and liberty
to make choices in accordance with his personal wishes, values and
cherished goals in life). (2) Non-malecence – to do or cause harms/evils
to the patient (on balance with benets). (3) Benecence – to actively
protect and promote the patient’s well-being and welfare, primarily as
perceived by him/her. (4) Distributive justice – pertains to the just and
fair distribution of nite health resources.
Please note the prima facie nature of these duties and obligations.

Making Ethical Choices
48
Making Ethical Choices
49
Q: Might the situation be such that a team member (or the
hospital) is simply failing to honour a specic ethical
obligation to a legitimate stakeholder?
Note: Health care professionals are generally very well meaning,
but it is conceivable that sometimes they might fail to identify
and honour specic duties and obligations to their patients,
albeit unwittingly.
Stage Five: Critical Analysis & Viable Alternatives
Stages 5 and 6 are closely related. The team progresses to a critical
analysis of the implicated duties and obligations. Further information
gathering and clarication might become necessary. One needs to employ
rationally justiable means of ‘prioritising’ those ethical principles that
conict.
Individuals from the team share their rationales for the positions
that they tend to favour. Following this, a brief re-examination of these
rationales is crucial because, not surprisingly, they might very well
become modied in the process.
Examine all viable alternatives, including the option of delayed
and non-intervention. Take into account the foreseeable consequences,
short and long term, of all viable possibilities. These necessarily include
all anticipated goods/benets as well as all anticipated harms/evils. The
probabilities of these are also crucial considerations.
It would be easier to initially exclude the alternatives that are totally
unacceptable. Develop a list of all ethically justiable resolutions from
the most desirable to the least. In so doing, juxtapose selected viable
alternatives with pertinent ethical duties and obligations or principles.
Caution: Scrutinise for clarity, congruence, consistency, coherence,
and adequacy.
Exclude decient alternatives. The team needs to reach consensus.
Dissenters might wish to drop out of the team at this stage of the process
if their moral positions are hopelessly irreconcilable with the preferred
alternatives.
Stage Six: Resolution Strategies with Preferential Scale
Rank the list of viable alternatives according to those choices that
appear most desirable (according to the criterion already specied). This
is a particularly important stage.
This means that it is possible to override a certain duty by another,
provided that there are rationally justiable reasons to believe that the
latter should have priority under the circumstances.
Q: What is the role of each stakeholder?
Note: The role of each stakeholder should be identied in order to
ensure clarity and consistency.
Q: What are the treatment team’s duties and obligations to the
patient, the patient’s immediate family, potential patients,
and society in general?
Note: Health care professionals’ primary obligation is to their
patients.
Q: Likewise, what are the hospital’s duties and obligations to
each of the above?
Q: What are the patient’s special responsibilities in his/her care
and treatment process?
Note: Responsibilities accompany rights, and these should be
identied as they pertain to the issue at hand.
Q: What obligations exist to legitimate third party stakeholders
(such as society and signicant other/s) as they pertain to this
case?
Stage Four: Identication of Specic Conict
Having determined the specic duties and obligations that are
pertinent, it becomes necessary to specify, as clearly as possible, what
conict exists, or whether there is a perception that someone is failing to
discharge his/her obligations adequately and effectively.
Q: What is the nature of the conict – might it be interpersonal
or even institution-based?
Note: Consider if the dilemma might have resulted from personal
conicts within the interdisciplinary team, between the
patient/signicant other and the treatment team, or between
the treatment team and the institution itself.
Q: What ethical principles or interests are in conict in this
situation?
Note: Consider if there might be a conict between benecence
and respect for the patient’s autonomy, or between respect
for patient autonomy and a perceived obligation to society.

Making Ethical Choices
50
Making Ethical Choices
51
Q: What choice is most congruent with the patient’s wishes,
values, and preferences, and what reasons, if any, exist to
suggest that these should not be honoured?
Q: What harms/evils should one be avoiding/preventing/
removing? How realistic is this?
Q: What benets should one be aiming towards? How realistic is
this?
Q: Have any promises been made (that require honouring)?
Q: Would staff be acting paternalistically, and is this rationally
justiable?
Q: Would anyone be exploited in the process and, if so, exactly
whom and why, and how can this be avoided?
Q: What choice is most likely to offer the best overall
consequences, short and long term?
Q: What choice is most likely to prevent the most harm, short
and long term, to stakeholders, especially the patient who
invariably has most at stake?
Q: Would any of the proposed choices violate the institutional
policies and values, the law and professional codes of
ethics?
Q: What choice would all stakeholders be most willing to live
with?
Q: What choice would serve as a good example for others in a
similar situation to follow?
Q: What choice is most justiable by appealing to universal
ethical principles rather than personal preferences?
Q: What do you honestly believe another reasonable group of
individuals would choose given the same circumstances?
Q: What if the staff and patient roles were reversed?
Q: Is there consensus that the anticipated end justied the
proposed means in this particular case?
Juxtapose each chosen and ranked alternative with the patient’s
values, beliefs and goals as determined directly from the patient (or from
a duly elected substitute decision-maker). Rank order those alternatives
that are most congruent with the patient’s own moral position. It is
important to remember that in health care practice most care and
treatments involve some harms/evils, for example, adverse effects. One
must always weigh these anticipated harms/evils against anticipated
benets, before implementing a course of action.
Sometimes, a reasonable compromise is to undertake an acceptable
course of action for a trial period, then reassess and re-evaluate efcacy
and sentiments held by major stakeholders.
There should be a fair process for stakeholders to resolve
intransigent disagreements and conicts, and this usually involves an
ethics committee, ethicist, or mediator.
Documentation is of paramount importance. Very careful
documentation of the content of all meetings and proceedings, including
names and roles of all participants should be undertaken.
Caution: Examine for clarity, coherence, consistency, congruence,
and adequacy. Briey check over the process to ensure that nothing
pertinent was excluded.
Stage Seven: Action Implementation
Before you attempt to implement the consensually-arrived at
decision, it is important to answer the following questions:
Q: Who is most appropriate to implement the choices arrived at,
and why?
Q: When is the best time to implement the decision, and why?
Q: When do you expect to see anticipated results?
Under most circumstances, no person should be expected to
implement a decision that he/she cannot live with. However, this maxim
must be tempered by the principle that no immediate harms/evils would
befall the patient by one’s non-participation. You do have certain duties
and obligations to your patient, and these must be carefully considered
when attempting to make a personal appeal to your conscience.
Stage Eight: Evaluation of Effectiveness
Q: Were the effects from the intervention those that were
expected, and did the decision resolve the specic dilemma
that one was faced with?
Q: Did the results occur within the time frame anticipated?
Q: Are there other consequences that were unforeseen, and
were new difculties created? Might these require further

Making Ethical Choices
52
Making Ethical Choices
53
deliberation and intervention?
Q: Was this decision the most ethically justiable under the
circumstances?
Stage Nine: Preventative Strategies
This is perhaps one of the most important stages in the process of
ethical decision-making.
Q: What can be learnt from the dilemma?
Q: What factors contributed to the dilemma?
Q: Are there problematic policies and procedures?
Q: Is there a need to modify current policies/procedures/
guidelines in order to prevent a recurrence in future?
It would be folly to believe and expect that the facility, clinician,
or care team could foresee every problematic situation. Because we are
dealing with rather elusive and changing phenomena such as values,
convictions, expectations and desires, ethical quandaries will arise in
the delivery of health care. However, once a dilemma occurs, we must
deal with it ethically, promptly and adequately. We must then critically
examine the entire circumstances of the situation in order to determine
the best strategy to prevent a recurrence. In this regard, the patient’s
input would be invaluable.
Conclusion
Clinical practice continues to be replete with ethical quandaries.
Individuals involved in health care systems and delivery – clinicians
and administrators alike – are grappling with new medico-technological
advances, changing societal values, attitudes, and expectations and a
rapidly increasing awareness of limited resources.
This handbook offers a comprehensive, readily applicable and
philosophically sound model that provides guidance in identifying
and resolving ethical quandaries in the care delivery process, both
administratively and clinically. In so doing, the authors have explored
changing paradigms in health care delivery with their new moral demands
and challenges, as well as far-reaching ramications that eventually affect
all stakeholders – patients, their families, clinicians, administrators and
health care policy makers, and society at large.
Morally reprehensible decisions are avoided, and the chances
of arriving at rationally justiable choices are signicantly increased.
Litigation consideration is a very important factor, and because it is
intimately intertwined with moral accountability in health care, litigious
situations are greatly reduced with a patient-centred, multidisciplinary
team approach.
This integrative, eclectic procedure initially involves a respectful,
focused, perceptive and sagacious discourse amongst all stakeholders,
then progresses toward a pursuit and reconciliation of common threads
of moral agreements. Consensus is enhanced, and the facilitated decision
is one that most, if not all, affected individuals could live with. In
this way, no individual is coerced or compelled to act against his/her
conscience. Allowance is left for dissenters to opt out should their moral
positions be hopelessly irreconcilable with the decision of the rest of the
team. (Prior to this, though, they would have considered their duties and
obligations, not only to their patient(s) and signicant others, but also to
their colleagues and other stakeholders.)
An alluring aspect of this model is its democratic thrust toward
decision-making in the clinical setting. It is consistent with liberal
democracy’s ethical norms and values. Major advantages to this
democratic impetus are collaborative, legitimate and committed
involvement by all pertinent players as well as shared responsibility
throughout the decision-making process. Through this involvement, the
values and opinions of all legitimate principals are duly considered and
form a vital component of the decision-making process. Thus, the most
rationally justiable decision – the ethical choice – is yielded.

Making Ethical Choices
54
Making Ethical Choices
55
Case Study
A starving patient with anorexia who refuses nutrition or
hydration
Miss Jones is a 45 year-old single woman with a 12 year history of
severe anorexia nervosa. She was admitted because of ambivalence about
life and rapidly decreasing weight – 69 pounds, which is approaching a
dangerously low level given her height. Miss Jones is only ingesting
small amounts (sips) of water. She denies active suicidal ideation or
plan. She has had at least 7 admissions in the previous 5 years, and she
was force-fed on 1 occasion. All therapy has so far failed. Although she
sometimes feels that she would be better off dead, Miss Jones does not
believe that her life is being compromised by her refusal of hydration
and nutrition. She emphatically refuses to be force-fed, claiming that
it had previously been a very degrading experience and violated her
basic values and beliefs. There is disagreement amongst the team (which
includes 2 physicians) concerning how to care for Miss Jones in this
situation. Miss Jones’ closest relative, her father, feels that he is not in
a position to override his daughter’s wishes. What ought to be done?
Why?
Stage One: Information Gathering
The main stakeholder is the patient. A particular course of action,
albeit not to intervene to force-feed, could lead to her demise. Other
stakeholders include her signicant others, in particular, her father.
Her father is already involved in decisions relating to her care, and it
is important to ensure that either there is a Form 14 signed authorizing
such involvement or that the patient has been determined to be mentally
incompetent and her father is the duly elected substitute decision maker.
Should the patient have an advance directive or living will, then this
should be respected. (Having said this, it is important to remember that
it is not in keeping with acceptable standards of health care practice to
accept or respect suicide notes as legitimate living wills. If the patient
does not have a terminal illness, the legitimacy of her request not to be
hydrated or force-fed is questionable.)
Other stakeholders are staff members and the hospital. Staff
members have their personal and professional integrity to maintain and
the decisions that they make should be such that they could live with and
should reect acceptable professional practice. Additionally, staff and
the hospital could be held liable for failure to provide due care including
failure to rescue.
The patient’s current wishes are not to eat or drink. The patient denies
being suicidal or of this being her plan to die. Yet, the patient’s current
course will inevitably lead to her demise. There seems to be a lack of
congruence between the patient’s beliefs and wishes and the decision
she is currently making. In determining capacity, one of the criteria is
to ensure that the patient possesses an understanding and appreciation
of her illness and the consequences of each viable alternative including
delayed and non-intervention.
An understanding pertains to the actual disease process, and an
appreciation relates to how the course of the disease impacts the specic
individual. In other words, appreciation personalizes the physical,
psychological, spiritual and emotional impact of the illness on the
affected individual. In this instance, it appears that the patient fails to
meet this criterion. It is important to note that the failure to meet the
criteria for capacity is not based on the actual decision, but partly on the
lack of congruence between her beliefs and values and her choices. (It
is important to remember that irrationality, by itself, does not constitute
incompetency.) It’s important that the team arrives at decision with
regard to the patient’s competency.
It seems as if the team needs to arrive at decision promptly given
the patient’s rapidly deteriorating condition.
Stage Two: Separation of Legal, Clinical & Ethical Facets
This dilemma comprises a predominantly ethical component because
the most pressing issue relates to a value conict (the right to autonomy
versus the duty to benecence). The duty to rescue stems from this moral
dimension.
Stage Three: Pertinent Ethical Duties & Obligations
Autonomy: The patient neither wishes to eat or drink nor to be force-
fed. The patient’s ability to make autonomous decisions is questionable.
The patient does not have an advance care directive or living will.
Benecence and non-malecence: Very serious harms will befall
the patient if her current wishes are respected – she will die. This could be
viewed as medical negligence. Other stakeholders (family and staff) may
feel guilty for not intervening to rescue her. On a burden/benet analysis:
Force-feeding could result in the patient feeling embittered toward family
and staff for overriding her wishes, and this might negatively impact her

Making Ethical Choices
56
Making Ethical Choices
57
personal and therapeutic relationships.
There is considerable discomfort associated with force-feeding,
and this may include complications from naso-gastric feeding and more
invasive procedures such as a gastrostomy. It might also include physical
and chemical restraints to keep the patient from pulling out her feeding
and hydration tubes. Anticipated benets include saving the patient’s life
and restoring her ability to make autonomous choices. Not intervening
or delayed intervention would, on the other hand, result in the patient’s
death, which, despite ambivalence about life, the patient does not wish.
Justice: Despite the chronicity of her disorder and the need for
ongoing care even though she sometimes refuses this, the patient is
entitled to a ‘fair’ share of health care resources. The general rule of
thumb is what would another reasonable interdisciplinary treatment
team most likely provide under similar circumstances.
Stage Four: Identication of Conict
There are numerous problems but the primary one relates to whether
or not the patient should be force-fed. This is a conict between the
principles of benecence and respect for autonomy.
Stage Five: Critical Analysis & Viable Alternatives
There is a legal duty to rescue patients who are in imminent and
serious danger. If, however, this patient were terminally ill, then
perhaps it would be morally permissible to forego force-feeding, as
it would be undesirable to prolong death with extravagant medical
intervention.66 Palliative care would be the most appropriate under such
circumstances.
It is, therefore, extremely important to determine whether in fact
the patient is terminally ill, for example, suffering from heart failure
or multiple organ failure due to severe and advanced anorexia. Expert
consultation in this regard becomes extremely important.
The wishes of adult patients who are incontrovertibly competent
to consent to, and refuse, treatments should under most circumstances
be respected. Patients for whom medical intervention will most likely
not benet any longer, thus not fullling one of the primary goals of
health care, would perhaps be better cared for through palliation. There
is no obligation on health care professionals to provide medically futile
treatments. Futility in this context means that the intervention is highly
unlikely to achieve the ends that it is intended to or, indeed, the goals of
health care.
Stage Six: Resolution Strategy with Preferential Scale
The treatment team could decide not to force-feed the patient, but
this would inevitably lead to her demise. The fact that she lacks capacity
to consent to, or refuse, treatment is extremely important, because it then
becomes incumbent on the treatment team to rescue her from preventable
suffering and death. It is possible to argue that her elderly father needs
to understand and appreciate the consequences of all viable options. The
patient’s father needs all pertinent information relating to his daughter’s
condition so that he would make an informed decision.
The treatment team would need to also consider the father’s
emotional attachment to his daughter, and every effort should be made to
foster an atmosphere that would promote the patient’s best interest (and
prior expressed capable wishes if known), the team’s primary obligation.
The treating team should attempt to negotiate an acceptable approach
with the patient and her father. Seeking ethics and legal counsels would
be prudent. Should the father refuse to give consent for force-feeding, the
treatment team should seek urgent counsel with the Consent & Capacity
Board. The Mental Health Act allows for alternative proxy, such as
another family member or a Public Guardian & Trustee, in situations
where the substitute decision-maker is viewed as not acting in accordance
with legislative requirements for substitute decision-making.
It is crucial to remind substitute decision makers that what is
essentially required of them is decisions based on the patient’s values,
beliefs and preferences rather than what they themselves might choose
under the circumstances.
Stage Seven: Action Implementation
Despite the patient’s refusal to consent to nutrition and hydration,
the decision and rationales should be explained to the patient, addressing
all questions and concerns that the patient might have. Every attempt
must be made to engage and collaborate with the patient and her father.
Ideally with the father’s consent, the patient should be transferred to an
appropriate unit for forced-feeding, where it will be administered with
the least possible intrusion, with compassion, and only for as long as
it is necessary (before she regains capacity). When the patient regains
capacity to make competent care decisions, then these ought to be
respected.

Making Ethical Choices
58
Making Ethical Choices
59
Stage Eight: Evaluation of Effectiveness
It is crucial to determine how effective the medical intervention
(force-feeding) has been. The central goals are to rescue the patient from
a life-threatening medical crisis, at least until her capacity has been re-
established. Therefore, it is important to assess for medical stability and
competency to consent to, or refuse, treatments.
Stage Nine: Preventative Strategies
Unfortunately, such complex medico-ethical situations will
occasionally occur in health care, given the nature of severe and
persistent illness and the morally diverse environment wherein health
care practice occurs. However, once these situations occur, it is of
paramount importance to act promptly, using a clear and methodological
decision-making process, in order to arrive at morally justiable choices.
Advance Care Directives can be extremely useful in these situations and
its use should be strongly encouraged when patients possess the capacity
to undertake advance care planning.
The use of the decision-making model is invaluable in critically
working through the dilemma, ensuring that all pertinent interests are
duly considered and weighed and all biases and prejudices are identied
and kept in check.
Endnotes
Introduction
1 Howard Brody, Ethical Decisions in Medicine (Boston: Little Brown
and Company, 1981) pp. 5-11.
2 Sheila Bunting and Adele Webb, “An Ethical Model for Decision-
Making,” Nurse Practitioner, 1988:13(12) pp. 30-34.
3 J. Thompson and H. Thompson, Bioethical Decision-making for
Nurses (Norwalk, Ct.: Appleton-Century-Croft, 1985).
4 Mary Murphy and James Murphy, “Making Ethical Decisions –
Systematically,” Nursing, May 1976, pp. 13-14.
5 Mila Aroskar, “Anatomy of an Ethical Dilemma: The Theory,”
American Journal of Nursing, April 1980, pp. 658-660.
6 Mila Aroskar, “Anatomy of an Ethical Dilemma: The Practice,”
American Journal of Nursing. April 1980, pp. 661-663.
7 L. Curtin and M. Flaherty, Nursing Ethics: Theories and Pragmatics.
(Virginia, Maryland: Prentice-Hall Int., 1992) pp. 57-63.
8 R. Grundstein-Amado, “An Integrative Model Of Clinical-Ethical
Decision-making,” Theoretical Medicine, 1991:12, pp. 157-170.
9 L. McCullough, “A Primer on Bioethics,” Seminar given to American
College of Physician Executives in 1994. Unpublished. pp. 1-35.
10 A. Jonsen, M. Siegler, and W. Winslade, Clinical Ethics (New York:
McGraw-Hill, Inc., 1992).
11 College of Nurses of Ontario, Guidelines for Professional Behaviour
(Toronto: College of Nurses of Ontario, 1995) pp. 1-17.
12 Paula Chidwick, “Approaches To Clinical Ethical Decision-Making:
Ethical Theory, Casuistry and Consultation” (Unpublished PhD
thesis, 1994) p. 116.
Ethics
13 Raanan Gillon, Philosophical Medical Ethics (Chichester: John
Wiley and Sons for The British Medical Journal, 1986) p. 2.
14 There are tomes of information concerning the philosophy of religion
and spirituality. As an example, please see M. Peterson, W. Hasker,
B. Reichenbach, and D. Basinger, Reason & Religious Belief (New
York: Oxford University Press, 1991).
Ethical Approaches
15 Other common ethical theories include natural law and divine
command theory. For a detailed discussion of these legitimate sources
of morality, please refer to T. Beauchamp and J. Childress, Principles
of Biomedical Ethics (New York: Oxford University Press, 1994);

Making Ethical Choices
60
Making Ethical Choices
61
John Arras and Nancy Rhoden, Ethical Issues in Modern Medicine
(California: Mayeld Publishing Co., 1989); Thomas Mappes and
Jane Zembaty, Biomedical Ethics (New York: McGraw-Hill Inc.,
1991); Tom Beauchamp and LeRoy Walters, Contemporary Issues
In Bioethics (California: Wadsworth Publishing Co., 1982).
16 J. S. Mill, Utilitarianism in J.S. Mill and J. Bentham, Utilitarianism
and Other Essays, ed. A. Ryan (Harmondsworth: Penguin, 1987).
17 I. Kant, Groundwork of the metphysics of morals (London: Harper
and Roaw, 1964). Translated and analysed by H.J. Paton.
18 Casuistry is not necessarily exclusive of the application of moral
principles, and Paul Ramsey, an eminent Anglican writer on medical
ethics, advocates a very rigorous form of casuistry in which he
combines diligent attention to detail with an equally conscientious
attention to theological principles. For detailed discussions on
the casuistry approach, please refer to Paul Ramsey, The Patient
As Person (Mass.: Yale University Press, 1975); Albert Jonsen,
Mark Siegler, and William Winslade, Clinical Ethics (New York:
McGraw-Hill, Inc., 1992); Albert Jonsen and S. Toulmin, The Abuse
of Casuistry (Berkley: University of California Press, 1988).
19 This approach promotes a multidisciplinary team consultation
perspective.
20 Meta-ethics is basically the inquiry about the meaning of ethical
terms and concepts (for example, ‘mental competency’, ‘rationality’,
and ‘personhood’) as well as the relation of ‘facts’ to values.
21 Descriptive ethics is basically the inquiry into the moral perspectives
held by various individuals and diverse cultures, as well as whether
any of these views are universally held.
Dening Ethical Dilemmas
22 It is possible to argue that circumstances objectively change cases.
Consider, for example, Renford Bambrough’s argument that “To
suggest that there is a right answer to a moral problem is at once to
be accused of or accredited with a belief in moral absolutes. But it is
no more necessary to believe in moral absolutes in order to believe
in moral objectivity than it is to believe in the existence of absolute
space or absolute time in order to believe in the objectivity of
temporal and spatial relations and of moral judgements about them”.
Renford Bambrough, Moral Skepticism and Moral Knowledge (New
Jersey: Humanities Press, 1979) p. 33.
23 Moral decisions made in a health care institution should be reective
of the general norms and values of a particular society, and it is
possible to argue that the decision-making process and the resolution,
in particular, should also be readily accessible to the comprehension
and appreciation of most members of society. Health care institutions
are a vital part of our social (and political) structure, and there is an
inherent accountability and responsibility to the general public –
past, current, and potential patients. In the ethical decision-making
process, there are active participants (for example, health care
professionals, the patient and his signicant others) and there are
passive participants (for example, other citizens, past and potential
patients, as well as other health care professionals). This is a ‘cyclic-
type’ process. On the one hand, public opinion and outcry bear a
tremendous inuence on the events in an institution, sometimes in
a current case, but usually in future deliberations (because decisive
actions were already implemented). On the other hand, citizens gain
greater insights into the events that occur in health care institutions,
and these often inuence their expectations, for example, they would
reconsider the possibility of having easy access to a triple valve
cardiac operation if it were clear that this was not readily available
to everyone who was suffering from cardiac valve difculties.
Ethical Decisions
24 I. A. Thompson, K. M. Melia and K. M. Boyd, Nursing Ethics
(Edinburgh: Churchill Livingstone, 1988) p. 3.
25 A. V. Campbell, Moral Dilemmas in Medicine, (Edinburgh: Churchill
Livingstone, 1975) pp. 2-3.
26 M. A. Aroskar, “Anatomy of an Ethical Dilemma: The Theory,”
American Journal of Nursing, April 1980, p. 658.
27 Ibid, p. 658.
Ethical Consensus
28 By the very nature of moral decision-making, the individual should
be an autonomous participant, and the deliberated decision ought to
be void of coercion and manipulation.
29 To illustrate: moral decision-making in a cultural and moral
pluralistic modern health care institution (with a multidisciplinary
team approach) might be contrasted with the relative ease with
which ‘unanimity’ might be achieved in a local rural church.
30 One example is a person with schizophrenia who refuses
antipsychotic medication and presents an imminent danger to himself
and/or others; and/or demonstrates a grave lack of competence to
care for himself/herself; and whose mental condition would most
likely be signicantly improved by the proposed treatment. Before
any treatment commences, the patient has ready access to a Review

Making Ethical Choices
62
Making Ethical Choices
63
Board (which consists of a duly elected psychiatrist, a lay-person,
and a lawyer) which reviews the entire case and, in a quasi-judicial
hearing, weighs the arguments presented by both parties (that is,
the attending psychiatrist, primary nurse, and social worker, as well
as the patient and/or his/her alternative decision-maker, and his
signicant others). If so decided, treatment is administered to the
‘involuntary’ patient for a specied period following which another
review is conducted. Furthermore, the patient and/or his/her proxy,
as indeed, the attending psychiatrist, can appeal the decision made
by the Review Board to a District Court.
31 Kurt Bayertz, “Introduction: Moral Consensus as a Social and
Philosophical Problem,” The Concept of Moral Consensus, ed. Kurt
Bayertz (Netherlands: Kluwer Academic Publishers, 1994) p. 13.
32 Ibid., p. 13.
The Team
33 Patients are no longer submissive and passive agents who allow
doctors to decide, by themselves, what is in their (the patients’)
best interest. The shifting paradigm in health care delivery is taking
us toward increased ‘health care consumerism’, that is, toward
increased mutual consultation and collaboration between the patient
(the consumer) and health care providers. Today, with the more
assertive and better informed patient who now seeks an active part in
determining what happens to him/her, and because it is he/she who
has most at stake in the proceedings of ethical decision-making, it is
possible to argue that he/she has a right to be included in the process
by reason of respect for patient autonomy. Honouring of benecence
is also enhanced through the active involvement of the patient,
because he/she or his/her proxy has direct access to the proceedings
and his/her input – feelings, values, and opinions – would receive
due consideration. It should be remembered that opinions and values
might very well be modied during rational discourse, and this can
be very benecial to all concerned. In other words, simply because
the patient is a patient (and it is generally assumed that he/she may
be suffering, physically and/or emotionally), one should not hasten
to exclude him/her from actively participating in the process (unless
it is his/her expressed desire to be excluded), under the pretext that
he/she would perhaps nd the proceedings unbearably stressful –
this would be a paternalistic attitude. A most important feature of
the procedure is the democratic, impartial and benevolent nature
of the process itself. It is in such an atmosphere wherein diverse
alternatives in choices and perspectives are presented with rationally
justiable reasons for their viability and preference, that the patient
can best appreciate the situation in its entirety.
There are several patient-physician relationship models, and the
extent of the involvement of the patient in the ethical decision-making
process would depend on which of these models one endorses. Robert
M. Veatch offers several models: First, the ‘engineering model’ – the
clinician, as a scientist, operates in what he generally perceives to
be a purely empirical world, and values are marginalized or ignored
altogether. The clinician is “a plumber without any moral integrity.”
Second, the ‘priestly model’ – the physician is viewed as a priest.
The primary criticism, according to Veatch, is “one of generalization
of expertise: transferring of expertise in the technical aspects of a
subject to expertise in moral advice.” As a result, the clinician’s
moral authority dominates the patient and the patient’s freedom
and dignity are severely restricted. Third, the ‘collegial model’ –
this attempts to balance the two former models, and the physician
is viewed as the patient’s “pal”. There is shared dignity and trust
between both parties. However, Veatch points out that “ethnic, class,
economic, and value differences make the assumption of common
interest which is necessary for the collegial model to function a mere
pipe-dream.” This model is, therefore, unrealistic and impractical.
Lastly, the ‘contractual model’ – herein lie the virtues of truth-telling,
freedom, dignity, condentiality, and justice. Duties and obligations
are monitored and sanctioned by social systems. According to
Veatch, “In the contractual model, then, there is a real sharing of
decision-making in a way that there is a realistic assurance that
both patient and physician will retain their moral integrity.” This
handbook adopts the contractual model as being most appropriate
for the ethical decision-making process (as for the entire patient-
clinician relationship) because of its emphasis on mutual respect and
consideration of each other’s values and integrity. Please refer to
Robert M. Veatch, “Models for Ethical Medicine in a Revolutionary
Age,” Ethical Issues in Modern Medicine, ed. J. D. Arras and N. K.
Rhoden (California: Mayeld Publishing Press, 1989) pp. 52-55.
34 It is important to note that patient condentiality is an exceedingly
important consideration, and the inclusion of family members or
signicant others must only follow the explicit permission to do so
from the patient. Of course there are exceptions, for example, when
attempting to manage an emergency situation or when it is evident
that the patient is unable to himself/herself express this desire – the
use of caution and professional integrity and sensitivity, as well as
the involvement of duly appointed proxies are clearly warranted.

Making Ethical Choices
64
Making Ethical Choices
65
For detailed criteria of what constitutes a duly elected proxy, please
refer to T. Beauchamp and J. Childress, Principles of Biomedical
Ethics (New York: Oxford University Press, 1994).
35 A. Jameton, Nursing Practice: The Ethical Issues (New Jersey:
Prentice-Hall Inc., 1984). Also, please refer to Judith Wilkinson,
“Moral Distress in Nursing Practice: Experience and Effect,”
Nursing Forum, 1987/1988:1.
Effective Team Deliberation
36 A ‘prima donna’ may be differentiated from a legitimate leader
by reason of the fact that he/she tends to monopolize the group,
generally inuencing the proceedings by his/her personal agendas
and prejudices, and often creating an atmosphere replete with choas,
disrespect, and resentment.
37 Bruce Ackerman, “Why Dialogue,” The Journal of Philosophy,
1989:LXXXVI, p.15.
38 For example: from a pragmatic perspective, in discussing a pressing
case of whether or not a pregnant 13-year old rape victim ought
to be granted an abortion, it is perhaps much more prudent and
productive to consider the physical and psychological effects of
compelling the young girl to carry the unwanted foetus to term (as
well as the enormous adverse consequences of having an unwanted
child), rather than to engage in prolonged and usually unfruitful
debates regarding meta-ethical concepts such as ‘sanctity of life’
(unless this becomes the focus of an argument presented).
39 The patient’s values are relatively more important to other values
in the specic discussion because he/she has the most at stake. It is
not because his/her values are ‘superior’ in any general or absolute
sense.
Pitfalls to Avoid
40 L. McCullough, Primer on Bioethics (Unpublished, 1994) p. 4.
Fallacies
41 For a more detailed account of fallacies, please see Logic and
Rational Thought (St Paul, USA: West Publishing Company,
1992).
Personal Values
42 Health care professionals, by reason of their formal education and
(professional) experience, have been socially sanctioned/authorized
to diagnose and treat as deemed necessary within the competencies
of their professions and with the adult mentally competent patient’s
‘informed consent’. Once the clinician-patient relationship has been
established, the clinician generally provides the patient with a set of
treatment alternatives including his professional preference, and the
patient then not only has the right to choose from the alternatives
offered, but also to refuse any treatment.
43 According to the Mental Health Act, a patient can be held against
his/her will in a safe institution if he/she were considered an
imminent danger to himself/herself and/or to others. Please refer to
The Ministry of Health of Ontario, Rights and Responsibilities: A
Guide to the Mental Health Act, p. 3.
44 Joseph King, The Law of Medical Malpractice (Minnesota: West
Publishing Co., 1977) pp. 8-35.
45 A. Meagher, P. Marr, and R. Meagher, Doctors and Hospitals: Legal
Duties (Vancouver: Butterworths Canada Ltd., 1991).
Moral Reasoning
46 For a more detailed reading of moral maturity please see W. Hughes,
Critical Thinking (Peterborough, Ontario: Broadview Press, 1992).
The Law
47 Even within this century we have seen the lawful and systematic
discrimination of women and minorities (racial and cultural groups
as well as mentally challenged and disordered individuals). Consider,
for example, the indiscriminate sterilization of children considered
mentally retarded until only a couple of decades ago.
48 For a more detailed examination of the relationship between Biothics
and the law, please refer to D. Roy, J. Williams and B. Dickens,
Bioethics in Canada (Scarborough, Ontario: Prentice-Hall Canada
Inc., 1994).
49 A. Meagher, P. Marr, and R. Meagher, Doctors and Hospitals: Legal
Duties (Vancouver: Butterworths Canada Ltd., 1991).
50 For a more detailed account of liability risks in psychiatry, please
see A Comprehensive Guide to Malpractice: Risk Management
in Psychiatry, ed. Frederic Flach (New York: Hatherleigh Press,
1998).
Professional Code of Ethics
51 According to Sieghart (1982), “Professional codes, if they are to
be worth anything, cannot merely conne themselves to asserting
that there is a problem and leaving it at that – let alone leaving it
to the individual members of the profession to solve the complex
as best as they can, consulting their unguided consciences and
perhaps a few respected colleagues. At the least, such a code must

Making Ethical Choices
66
Making Ethical Choices
67
say something about how to approach this kind of problem.” P.
Sieghart, “Professional Ethics – for whose benet?” Journal of
Medical Ethics, 1982:8, pp. 25-32.
52 An examination of German psychiatrists’ “code of ethics” during
the Third Reich and their active participation in the elimination of
innocent and vulnerable people bear witness to atrocities conducted
by “trusted” professionals who had a duciary relationship with
them. See, for example, L. Lapon, Mass Murderers in white coats.
Psychiatric genocide in Nazi Germany and the United States
(Springeld, Il.: Psychiatric Genocide Research Institute, 1986).
Also, R. Lifton, The Nazi Doctors. Medical killing and the psychology
of genocide (New York: Basic Books, 1986). For an examination
of atrocities conducted by qualied Soviet psychiatrists, please see
M. Lader, Psychiatry on trial. (Harmondsworth: Penguin, 1977). Of
course, North Americans also have a legacy of detrimental abuse and
oppression of severely mentally ill patients, for example, through
medical research conducted at McGill University a few decades
ago.
Institution’s Mission, Values, Policies & Practices
53 Aristotle, Nicomachean Ethics, transl. W. D. Ross, revised by J.L
Ackrill and J.O. Urmson, (Oxford: Oxford University Press, 1980).
54 See, for example, H. Smith and A. Carroll, “Organizational Ethics:
A stacked Deck,” Journal of Busniess Ethics, 1984:3(2), pp. 95-
100.
55 For a more detailed examination of this concept please see L. Irving,
“Groupthink” Psychology Today. 1971 (in Staw), pp. 407-410. See
also C. Madden, “Forces Which Inuence Ethical Behaviour,” The
Ethics of Corporate Conduct, ed. Clarence Walton (New Jersey:
Prentice-Hall, Englewood Cliffs, 1977).
Ethical Principles & Guidelines
56 Simon, R. Psychiatry and Law for Clinicians (Washington, DC:
American Psychiatric Press, 1998).
57 In this regard, it is important to note that the primary justication for
breaching patients’ condentiality is serious risk of harm to oneself
and/or another (others). These situations include communicable
diseases (the Ontario Health Protection and Promotion Act), child
abuse (Child Protection Act), driving safety (under highway trafc
legislation), ying safety (under the Federal Aeronautics Act),
dangerous patients (the Mental Health Act and the duty to warn as
derived from the Tarasoff case), sexual misconduct (The Regulated
Health Care Professional Act in Ontario), vulnerable adults in
danger of serious harms (under the moral and legal duty to rescue
and care).
58 For an interesting examination of arguments relating to the role of
employees as ‘loyal’ agents, please see Business Ethics in Canada,
ed. D. Poff and W. Waluchow (Scarborough, Ontario: Prentice-Hall
Canada Inc., 1991).
The Virtues (compliment Ethical Principles)
59 Aristotle, Nicomachean Ethics, transl. W.D. Ross, revised by J.L
Ackrill and J.O. Urmson, (Oxford: Oxford University Press, 1980).
60 Aristotle, EN, II, p. 6.
Ethical Decision-Making Model
61 David Hume, An Enquiry Concerning the Principles of Morals, ed.
Eric Steinberg and J. B. Schneewind (Indiana: Hackett Publishing
Company Inc., 1983) pp. I, 15.
62 These are some of the ethical and legal requirements for mandatory
intervention. Please also refer to Endnote 26.
63 Alastair Campbell, Grant Gillett, and Gareth Jones, Practical
Medical Ethics (Aukland: Oxford University Press, 1992) p. 14.
64 H. Brody, Ethical Decisions in Medicine (Boston: Little, Brown and
Company, 1981) p. 7.
65 Even if it does not involve a predominantly clinical element, it is
important to remember that one would still need to incorporate
clinical considerations in the deliberation.
Case Study
66 Schneiderman, L., Faber-Langendoen, K., Jecker, N. “Beyond
futility to an ethic of care,” American Journal of Medicine, 1994:96,
pp. 110-114.

Making Ethical Choices
68
Making Ethical Choices
69
Bibliography
Aroskar, M. A. “Anatomy of an Ethical Dilemma: The Theory.” American
Journal of Nursing. April 1980, p. 658.
Bambrough, R. Moral Skepticism and Moral Knowledge. New Jersey:
Humanities Press, 1979.
Beauchamp, T. and Childress, J. Principles of Biomedical Ethics. New
York: Oxford University Press, 1994.
Brody, H. Ethical Decisions in Medicine. Boston: Little, Brown and
Company, 1981.
Poff, D. and Waluchow, W. (eds.) Business Ethics in Canada. Scarborough,
Ontario: Prentice-Hall Canada Inc., 1991.
Campbell, A., Gillett G. and Jones, G. Practical Medical Ethics. Aukland:
Oxford University Press, 1992.
Campbell, A.V. Moral Dilemmas in Medicine. Edinburgh: Churchill
Livingstone, 1975.
Gillon, R. Philosophical Medical Ethics. Chichester: John Wiley and
Sons for The British Medical Journal, 1986.
Hume, D. An Enquiry Concerning the Principles of Morals. Ed. Eric
Steinberg and J. B. Schneewind. Indiana: Hackett Publishing
Company Inc., 1983.
Jameton, A. Nursing Practice: The Ethical Issues. New Jersey: Prentice-
Hall Inc., 1984.
King, J. The Law of Medical Malpractice. Minnesota: West Publishing
Co., 1977.
Lader, M. Psychiatry on Trial. Harmondsworth: Penguin, 1977.
Lapon, L. Mass Murderers in White Coats. Psychiatric Genocide in
Nazi Germany and the United States. Springeld, Il.: Psychiatric
Genocide Research Institute, 1986.
Lifton, R. The Nazi Doctors. Medical Killing and the Psychology of
Genocide. New York: Basic Books, 1986.
Madden, C. “Forces Which Inuence Ethical Behaviour.” The Ethics of
Corporate Conduct. Ed. Clarence Walton. New Jersey: Prentice-
Hall, Englewood Cliffs, 1977.
McCullough, L. Primer on Bioethics. Unpublished, 1994.
Mill, J. S. On Liberty. Ed. A. Castell. Illinois: AHM Publishing

Making Ethical Choices
70
Making Ethical Choices
71
Corporation, 1947.
Peterson, M., Hasker, W., Reichenbach, B. and Basinger, D. Reason &
Religious Belief. New York: Oxford University Press, 1991.
Roy, D., Williams, J. and Dickens, B. Bioethics in Canada. Scarborough,
Ontario: Prentice-Hall Canada Inc., 1994.
Sieghart, P. “Professional Ethics – For Whose Benet?” Journal of
Medical Ethics. 1982:8, pp. 25-32.
Smith, H. and Carroll, A. “Organizational Ethics: A Stacked Deck.”
Journal of Busniess Ethics. 1984:3(2), pp. 95-100.
The Ministry of Health of Ontario. Rights and Responsibilities: A Guide
to the Mental Health Act.
Thompson, I. A., Melia, K. M. and Boyd, K. M. Nursing Ethics.
Edinburgh: Churchill Livingstone, 1988.
Veatch, R. M. “Models for Ethical Medicine in a Revolutionary Age.”
Ethical Issues in Modern Medicine. Ed. J. D. Arras and N. K.
Rhoden. California: Mayeld Publishing Press, 1989.
Wilkinson, J. “Moral Distress in Nursing Practice: Experience and
Effect.” Nursing Forum. 1987/1988:1.
Appendix 1: Canadian Medical
Association Code of Ethics
General Responsibilities
1. Consider rst the well-being of the patient.
2. Treat all patients with respect; do not exploit them for personal
advantage.
3. Provide for appropriate care for your patient, including physical
comfort and spiritual and psychosocial support even when cure is
no longer possible.
4. Practise the art and science of medicine competently and without
impairment.
5. Engage in lifelong learning to maintain and improve your professional
knowledge, skills and attitudes.
6. Recognize your limitations and the competence of others and when
indicated, recommend that additional opinions and services be
sought.
Responsibilities to the Patient
Initiating and Dissolving a Patient-Physician Relationship
7. In providing medical service, do not discriminate against any patient
on such grounds as age, gender, marital status, medical condition,
national or ethnic origin, physical or mental disability, political
afliation, race, religion, sexual orientation, or socio-economic
status. This does not abrogate the physician’s right to refuse to
accept a patient for legitimate reasons.
8. Inform your patient when your personal morality would inuence
the recommendation or practice of any medical procedure that the
patient needs or wants.
9. Provide whatever appropriate assistance you can to any person with
an urgent need for medical care.
10. Having accepted professional responsibility for a patient, continue
to provide services until they are no longer required or wanted;
until another suitable physician has assumed responsibility for the
patient; or until the patient has been given adequate notice that you
intend to terminate the relationship.

Making Ethical Choices
72
Making Ethical Choices
73
11. Limit treatment of yourself or members of your immediate family to
minor or emergency services and only when another physician is not
readily available; there should be no fee for such treatment.
Communication, Decision-making and Consent
12. Provide your patients with the information they need to make
informed decisions about their medical care, and answer their
questions to the best of your ability.
13. Make every reasonable effort to communicate with your patients in
such a way that information exchanged is understood.
14. Recommend only those diagnostic and therapeutic procedures
that you consider to be benecial to your patient or to others. If a
procedure is recommended for the benet of others, as for example
in matters of public health, inform your patient of this fact and
proceed only with explicit informed consent or where required by
law.
15. Respect the right of a competent patient to accept or reject any
medical care recommended.
16. Recognize the need to balance the developing competency of
children and the role of families in medical decision-making.
17. Respect your patient’s reasonable request for a second opinion from
a physician of the patient’s choice.
18. Ascertain wherever possible and recognize your patient’s wishes
about the initiation, continuation or cessation of life-sustaining
treatment.
19. Respect the intentions of an incompetent patient as they were
expressed (e.g., through an advance directive or proxy designation)
before the patient became incompetent.
20. When the intentions of an incompetent patient are unknown and
when no appropriate proxy is available, render such treatment as
you believe to be in accordance with the patient’s values or, if these
are unknown, the patient’s best interests.
21. Be considerate of the patient’s family and signicant others and
cooperate with them in the patient’s interest.
Condentiality
22. Respect the patient’s right to condentiality except when this right
conicts with your responsibility to the law, or when the maintenance
of condentiality would result in a signicant risk of substantial harm
to others or to the patient if the patient is incompetent; in such cases,
take all reasonable steps to inform the patient that condentiality
will be breached.
23. When acting on behalf of a third party, take reasonable steps to
ensure that the patient understands the nature and extent of your
responsibility to the third party.
24. Upon a patient’s request, provide the patient or a third party with
a copy of his or her medical record, unless there is a compelling
reason to believe that information contained in the record will result
in substantial harm to the patient or others.
Clinical Research
25. Ensure that any research in which you participate is evaluated both
scientically and ethically, is approved by a responsible committee
and is sufciently planned and supervised that research subjects are
unlikely to suffer disproportionate harm.
26. Inform the potential research subject, or proxy, about the purpose of
the study, its source of funding, the nature and relative probability of
harms and benets, and the nature of your participation.
27. Before proceeding with the study, obtain the informed consent of
the subject, or proxy, and advise prospective subjects that they have
the right to decline or withdraw from the study at any time, without
prejudice to their ongoing care.
Professional Fees
28. In determining professional fees to patients, consider both the nature
of the service provided and the ability of the patient to pay, and be
prepared to discuss the fee with the patient.
Responsibilities to Society
29. Recognize that community, society and the environment are
important factors in the health of individual patients.
30. Accept a share of the profession’s responsibility to society in matters
relating to public health, health education, environmental protection,
legislation affecting the health or well-being of the community, and
the need for testimony at judicial proceedings.
31. Recognize the responsibility of physicians to promote fair access to
health care resources.

Making Ethical Choices
74
Making Ethical Choices
75
32. Use health care resources prudently.
33. Refuse to participate in or support practices that violate basic human
rights.
34. Recognize a responsibility to give the generally held opinions of
the profession when interpreting scientic knowledge to the public;
when presenting an opinion that is contrary to the generally held
opinion of the profession, so indicate.
Responsibilities to the Profession
35. Recognize that the self-regulation of the profession is a privilege
and that each physician has a continuing responsibility to merit this
privilege.
36. Teach and be taught.
37. Avoid impugning the reputation of colleagues for personal motives;
however, report to the appropriate authority any unprofessional
conduct by colleagues.
38. Be willing to participate in peer review of other physicians and to
undergo review by your peers.
39. Enter into associations only if you can maintain your professional
integrity.
40. Avoid promoting, as a member of the medical profession, any
service (except your own) or product for personal gain.
41. Do not keep secret from colleagues the diagnostic or therapeutic
agents and procedures that you employ.
42. Collaborate with other physicians and health professionals in the
care of patients and the functioning and improvement of health
services.
Responsibilities to Oneself
43. Seek help from colleagues and appropriately qualied professionals
for personal problems that adversely affect your service to patients,
society or the profession.
Reprinted with permission from the Canadian Medical Association.
Appendix II: Canadian Nurses
Association Code of Ethics
CLIENTS
I
A nurse is obliged to treat clients with respect for their individual
needs and values.
Standards
1. Factors such as the client’s race, religion, ethnic origin, social status,
sex, age or health status may not be permitted to compromise the
nurse’s commitment to that client’s care.
2. The expectations and normal life patterns of clients are acknowledged
individualized programs of nursing care are designed to accommodate
the psychological, social, cultural and spiritual needs of clients, as
well as their biological needs.
3. The nurse does more than respond to the requests of clients, by
accepting an afrmative obligation to aid clients in their expression
of needs and values within the context of health care.
4. Recognizing the client’s membership in a family and a community,
the nurse, with the client’s consent, attempts to facilitate the
participation of signicant others in the care of the client.
II
Based upon respect for clients and regard for their right to control
their own care, nursing care should reect respect for the right of choice
held by clients.
Standards
1. The competent client’s consent is an essential precondition to the
provision of health care. Nurses bear the primary responsibility to
inform clients about the nursing care that is available to them.
2. Consent may be signied in many different ways. Verbal permission
or knowledgeable cooperation are the usual forms in which clients
consent to nursing care. In each case, however, a valid consent
represents the free choice of the competent client to undergo that
care which is to be provided.
3. Consent properly understood is the process by which a client

Making Ethical Choices
76
Making Ethical Choices
77
becomes an active participant in care. All clients should be aided
in becoming active participants in their care to the maximum extent
that circumstances permit. Professional ethics may require of the
nurse actions that exceed the legal requirements of consent. For
example, although a child may be legally incompetent to consent,
nurses should nevertheless attempt to inform and involve the child
in treatment.
4. Force, coercion and manipulative tactics must not be employed in
the obtaining of consent.
5. Illness or other factors may compromise the client’s capacity for self-
direction. Nurses have a continuing obligation to value autonomy
in such clients, for example, by creatively providing them with
opportunities for choices, within their capabilities, thereby aiding
them to maintain or regain some degree of autonomy.
6. Whenever information is provided to a client, this must be done in a
truthful, understandable and sensitive way. it must proceed with an
awareness of the individual client’s needs, interests and values.
7. Nurses should respond freely to their client’s requests for
information and explanation when in possession of the knowledge
required to respond accurately. When the questions of the client
require information beyond that of the nurse, the client should be
informed of that fact and referred to a more appropriate health care
practitioner for a response.
III
The nurse is obliged to hold condential all information regarding a
client learned in the health care setting.
Standards
1. The rights of persons to control the amount of personal information
that will be revealed applies with special force in the health care
setting. It is, broadly speaking, up to clients to determine who shall
be told of their condition, and in what detail.
2. In describing professional condentiality to a client, its boundaries
should be revealed:
a) Competent care requires that other members of a team of health
personnel have access to or be provided with the relevant details
of a client’s condition.
b) In addition, discussions of the client’s care may be required
for the purpose of teaching, research or quality assurance.
In this case, special care must be taken to protect the client’s
anonymity. Whenever possible, the client should be informed
of these necessities at the onset of care.
3. An afrmative duty exists to institute and maintain practices that
protect client condentiality, for example, by limiting access to
records.
Limitations
The nurse is not morally obligated to maintain condentiality when
the failure to disclose information will place the client or third parties in
danger. Generally, legal requirements to disclose are morally justied
by these same criteria. In facing such a situation, the rst concern of the
nurse must be the safety of the client or the third party.
Even when the nurse is confronted with the necessity to disclose,
condentiality should be preserved to the maximum possible extent.
Both the amount of information disclosed and the number of people to
whom disclosure is made should be restricted to the minimum necessary
to prevent the feared harm.
IV
The nurse has an obligation to be guided by consideration for the
dignity of clients.
Standards
1. Nursing care should be carried out with consideration for the
personal modesty of clients.
2. A nurse’s conduct at all times should acknowledge the client as a
person. For example, discussion of care in the presence of the client
should actively involve or include that client.
3. As ways of dealing with death and the dying process change, nursing
is challenged to nd new ways to preserve human values, autonomy
and dignity. In assisting the dying client, measures must be taken to
afford as much comfort, dignity and freedom from anxiety and pain
as possible. Special consideration is given to the need of the client’s
family to cope with their loss.
V
The nurse is obligated to provide competent care to clients.

Making Ethical Choices
78
Making Ethical Choices
79
Standards
1. Nurses should engage in continuing education and in the upgrading
of skills relevant to the practice setting.
2. In seeking or accepting employment, nurses should accurately state
their areas of competence as well as limitations.
3. Nurses who are assigned to work outside of an area of present
competence should seek to do that which, under the circumstances,
is in the best interests of their clients. Supervisors or others should
be informed of the situation at the earliest possible moment so that
protective measures can be instituted. As a temporary measure, the
safety and welfare of clients may be better served by the best efforts
of the nurse under the circumstances than by no nursing care at all.
4. When called upon outside of an employment setting to provide
emergency care, nurses fulll their obligations by providing the best
care that circumstances, experience and education permit.
Limitations
A nurse is not ethically obliged to provide requested care when
compliance would involve a violation of her or his moral beliefs. When
that request falls within recognized forms of health care, however, the
client should be referred to a more appropriate health care practitioner.
Nurses who have or are likely to encounter such situations are morally
obligated to seek to arrange conditions of employment so that the care of
clients is not jeopardized.
VI
The nurse is obliged to represent the ethics of nursing before
colleagues and others.
Standards
1. Nurses serving on committees concerned with health care or research
should see their role as including the vigorous representation of
nursing’s professional ethics.
2. Many public issues include health as a major component.
Involvement in civic activities may afford the nurse the opportunity
to further the objectives of nursing as well as to fulll the duties of
a citizen.
VII
The nurse is obligated to advocate the client’s interest.
Standards
1. Advocating the interests of the client includes assistance in achieving
access to quality health care. For example, by providing information
to clients privately or publicly, the nurse enables them to satisfy
their rights to health care.
2. When speaking to public issues or in court as a nurse, the public is
owed the same duties of accurate and relevant information as are
clients within the employment setting.
VIII
In all professional settings, including education, research and
administration, the nurse retains a commitment to the welfare of clients.
The nurse bears an obligation to act in such a fashion as will maintain
trust in nurses and nursing.
Standards
1. Nurses accepting professional employment must ascertain that
conditions will permit provision of care consistent with the values
and standards of the Code. Prospective employers should be
informed of the provisions of the Code so that realistic and ethical
expectations may be established at the beginning of the nurse-
employer relationship.
2. Accurate performance appraisal is required by a concern for present
and future clients and is essential to the growth of nurses. Nurse
administrators and educators are morally obligated to provide timely
and accurate feedback to nurses, and their supervisors, student
nurses and their teachers.
3. Administrators bear special ethical responsibilities that ow from a
concern for present and future clients. The nurse administrator seeks
to ensure that the competencies of personnel are used efciently.
Working within available resources, the administrator seeks to
ensure the welfare of clients. When competent care is threatened due
to inadequate resources or for some other reason, the administrator
acts to minimize the present danger and to prevent future harm.
4. An essential element of nursing education is the student-client
encounter. This encounter must be conducted in accordance with
ethical nursing practices, with special attention to the dignity of
the client. The nurse educator is obligated to ensure that nursing

Making Ethical Choices
80
Making Ethical Choices
81
students are acquainted with and comply with the provisions of the
Code.
5. Research is necessary to the development of the profession of
nursing. Nurses should be acquainted with advances in research,
so that established results may be incorporated into practice. The
individual nurse’s competencies and circumstances may also be
used to engage in, or to assist and encourage research designed to
enhance the health and welfare of clients.
The conduct of research must conform to ethical nursing practice.
The self-direction of clients takes on added importance in this context.
Further direction is provided in the Canadian Nurses Association
publication entitled, Ethical Guidelines for Nursing Research Involving
Human Subjects.
HEALTH TEAM
IX
Client care should represent a cooperative effort, drawing upon
the expertise of nursing and other health professions. Acknowledging
personal or professional limitations, the nurse recognizes the perspective
and expertise of colleagues from other disciplines.
Standards
1. The nurse participates in the assessment, planning, implementation
and evaluation of comprehensive programs of care for clients. The
scope of a nurse’s responsibility should be based upon education
and experience, as well as legal considerations of licensure or
registration.
2. The nurse accepts a responsibility to work with others through
professional nurses’ associations to secure quality care for clients.
X
The nurse, as a member of the health care team, is obliged to take
steps to ensure that the client receives competent and ethical care.
Standards
1. The rst consideration of the nurse who suspects incompetence or
unethical conduct should be the welfare of present clients or potential
harm to future clients. Subject to that principle, the following should
be considered:
a) The nurse is obliged to ascertain the facts of the situation in
deciding upon the appropriate course of action.
b) Institutional mechanisms for reporting incidents or risks of
incompetent or unethical care should be followed.
c) It is unethical for a nurse to participate in efforts to deceive or
mislead clients regarding the cause of their injury.
d) Relationships in the health care team should not be disrupted
unnecessarily. If a situation can be resolved without peril to
present or future clients by direct discussion with the colleague
suspected of providing incompetent or unethical care, that
should be done.
2. The nurse who attempts to protect clients threatened by incompetent
or unethical conduct may be placed in a difcult position. Colleagues
and professional associations are morally obliged to support nurses
who fulll their ethical obligations under the Code.
3. Guidance concerning those activities that may be delegated
by nurses to assistants and other health care workers is found in
legislation and policy statements. When functions are delegated,
the nurse should be satised regarding the competence of those who
will be fullling these functions. The nurse has a duty to provide
continuing supervision in such a case.
THE SOCIAL CONTEXT OF NURSING
XI
Conditions of employment should contribute to client care and to the
professional satisfaction of nurses. Nurses are obliged to work towards
securing and maintaining conditions of employment that satisfy these
connected goals.
Standards
1. In the nal analysis, the improvement of conditions of nursing
employment is often to the advantage of clients. Over the short term
however, there is a danger that action directed toward this goal will
work to the detriment of clients. Nurses bear an ethical responsibility
to present as well as future clients and so the following principles
should be noted:
a) The safety of clients should be the rst concern in planning and

Making Ethical Choices
82
Making Ethical Choices
83
implementing any job action.
b) Individuals and groups of nurses participating in job actions
share this ethical commitment to the safety of clients. However,
their responsibilities may lead them to express this commitment
in different, but equally appropriate ways.
c) Clients whose safety requires ongoing or emergency nursing
care are entitled to have those needs satised throughout the
duration of any job action. Members of the public are entitled
to know of the steps that have been taken to ensure the safety of
clients.
d) Individuals and groups of nurses participating in job actions
have a duty of coordination and communication to take steps
reasonably designed to ensure the safety of clients.
RESPONSIBILITIES OF THE PROFESSION
XII
Professional nurses’ organizations recognize a responsibility to
clarify, secure and sustain ethical nursing conduct. The fulllment of
these tasks requires that professional organizations remain responsive to
the rights, needs and legitimate interests of clients and nurses.
Standards
1. Sustained communication and cooperation between the Canadian
Nurses Association, provincial associations and other organizations
of nurses, is an essential step towards securing ethical nursing
conduct.
2. Professional nurses’ associations must at all times accept
responsibility for assuring quality care for clients.
3. Professional nurses’ associations have a role in representing nursing
interests and perspectives before non-nursing bodies, including
legislatures, employers, the professional organizations of other
health disciplines and the public media of communication.
4. Professional nurses’ associations should provide and encourage
organizational structures that facilitate ethical nursing conduct.
a) Changing circumstances may call for reconsideration and
adaptation of this Code. Supplementation of the code may be
necessary in order to address special situations. Professional
associations should consider the ethics of nursing on a regular
and continuing basis and be prepared to provide assistance to
those concerned with its implementation.
b) Education in the ethical aspects of nursing should be available
to nurses throughout their careers. Nurses’ associations should
actively support or develop structures designed towards this
end.
Reprinted with permission from the Canadian Nurses Association.

Homewood and Guelph, Ontario
The Homewood Health Centre sits on the crest of rolling grounds
that meets the Speed River in a delicate intersection of nature’s best. Its
porticos reect the history the Homewood embodies.
Founded 115 years ago, Homewood is one representative of how
public enterprise and public medicare can work together. Homewood
is privately owned, but provides a public service, treating people with
mental, behavioural and emotional disorders with a mix of modern
science and spiritual safety.
Homewood’s legacy has been penned by the dedication of pioneers
like Stephen Lett, its rst superintendent, who projected a holistic vision
and out-comes based care well ahead of his time. The progression
continues.
Homewood today is an internationally known specialist in addiction
medicine, trauma care and treatment of depression, eating disorders and
other forms of psychiatric and emotional illness.
Ken Murray and Bill Hamilton lead the Homewood Corporation,
Mr. Murray as Chairman, and Mr. Hamilton as President. Both hold
strong beliefs in the parallel courses of clinical and community service
that Homewood has come to represent.
The Homewood Corporation is the holding company for the Health
Centre, the Homewood Behavioural Corporation and Orangewood
Properties Ltd., a property management and retirement home investment
company. Two million shares of the Homewood Corporation are traded
publicly and distributed widely.
Guelph, Ontario, is Homewood’s hometown. A city with a population
of 84,000, a strong manufacturing base, a professional and university
community, and a well-run local economy, Guelph represents a classic
blend of aesthetics, history and planned growth. It is a smaller Canadian
city nestled between bigger communities to the west and Canada’s
biggest metropolis, Toronto, an hour to the east.

“Making Ethical Choices is a ‘must read’ for clinicians and
administrators. Our professional training has often missed translating into
sound, understandable terms, denitions and concepts related to ethics.
Nor are professional schools always able to offer necessary, practical
tools to assist the learning practitioner through perplexing choices and
dilemmas. Fortunately, through the systematic utilization of a logical
decision-making model, this handbook serves to educate and guide the
reader to analyze the situation at hand; review possible choices and
strategies; and seek collaborative, responsible and ethical decisions.”
Jill Herne, RN, CPMHN(C), BA, MS, CHE, Director of Patient Care
and Chief Nursing Ofcer, Homewood Health Centre.
“There is a very pressing need for lucid ethical direction in our
complex health care system with diverse values and interests. This
handbook provides a clear outline of philosophical principles and a
logical and practical ethical decision-making process as they pertain
to health care delivery. It is a well-organized overview of the basis for
ethical decision-making, and will be an invaluable guide to health care
professionals and administrators in the identication and resolution of
ethical dilemmas.”
Reid Finlayson, MD, FRCP(C), FAPA, Clinical Associate Professor of
Psychiatry, McMaster University.

Regional Centre for Excellence in Ethics
Homewood Health Centre Inc.
www.homewood.org
www.ethika.ca