Ethics theories and approaches: conceptual tools for ethical decision making
Objectives
• Distinguish between an ethical theory and ethical approach.
• Understand the process of clinical reasoning in the health professional.
• List the different modes of clinical reasoning.
• Describe ethical reasoning as a distinct mode of clinical reasoning.
• Describe a narrative and what it means to take a narrative approach to an ethical issue or problem.
• Assess the contribution of psychologist Carol Gilligan and others who stress relationships.
• Relate the basic features of an “ethic of care” to “a caring response,” introduced in Chapter 2.
• Describe the function of a principle (norm, element) in ethical analysis and conduct.
• Describe the principle of veracity as it applies in the professional context.
New terms and ideas you will encounter in this chapter
clinical reasoning
ethical reasoning
theories and approaches
normative ethics
metaethics
story or case approaches
foundationalist based
narrative approaches
postmodernists
ethics of care approach
virtue theory
character trait
moral character
principles
principle-based approach
nonmaleficence
beneficence
autonomy and self-determination
fidelity
veracity
paternalism
justice
deontology
deontologic theories
teleology
absolute duties
prima facie duties
conditional duties
teleologic theories
utilitarianism
rule utilitarian
Topics in this chapter introduced in earlier chapters
| Topic | Introduced in chapter |
| Three uses of ethics in everyday life | 1 |
| Moral duty and character | 1 |
| Codes of ethics | 1 |
| A caring response | 2 |
| Patient-centered care | 2 |
| Professional responsibility | 2 |
| Right(s) | 2 |
| Prototypes of ethical problems | 3 |
| Moral agent | 3 |
| Moral distress | 3 |
| Ethical dilemma | 3 |
Introduction
In this chapter, you will be introduced to a whole “toolbox” of conceptual tools you can use to accomplish your professional goal of arriving at a caring response in the wide variety of challenges you may encounter. These tools are presented in the form of ethical theories and ethical approaches. An ethical theory is researched and well developed and provides us with an assumption about the very nature of doing right and wrong. Most are historically based and have evolved for current usage according to a society’s or group’s development and need for interpreting or addressing current moral challenges. In contrast, an approach does not propose to be a complete system or model but an aid to existing theories. For instance, the principle-based approach to which you will be introduced in this chapter is quite recent and has roots in ancient Western ethical theories. Both ethical theories and approaches provide you with a framework for diagnosing, communicating, and problem solving ethical questions you encounter in your clinical practice.1
If you are like us, you probably take a look at how many pages you have ahead of you for your assignment and you quickly conclude that this is a very long siege of reading! The idea behind this chapter is to provide you with a “mini book” of ethical theory. Depending on your course of study, your professor may add to these pages with another more theoretic text or may split the chapter into smaller parts. We encourage you to work your way through the chapter carefully so that the rest of your study of this book is easier and your preparation in ethics more complete.
In Chapter 1, we suggested three general ways that ethical tools have usefulness in your everyday life: (1) to analyze moral issues, (2) to help resolve moral conflicts, and (3) to move toward action when faced with a problem. In Chapter 2, you learned about the caring response as the goal of professional ethical practice. In Chapter 3, you had an opportunity to learn the basic varieties (i.e., prototypes) of ethical problems you will encounter in your professional career. In this chapter, you will gain more knowledge and tools that enable you to move skillfully from the identification of a problem, through its analysis, and, hopefully, to its resolution through action that achieves your goal of a caring response. Chapter 5 provides a simple six-step process you can follow as you apply everything discussed in this and the previous chapters. To help set the stage for your thinking, consider the story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary.
The Story of Elizabeth Kim, Max Diaz, Melinda Diaz, and Michael Leary
A speech and language pathologist, Elizabeth Kim, works in a large urban school system. She is responsible for performing many student evaluations and interventions each day and takes her job seriously. Elizabeth services the Richards Elementary School and two other schools in the Lakeview district. Students and parents who meet Elizabeth quickly learn that she is a bright spot in the otherwise anxiety-producing ordeal of navigating services for children with learning disabilities. Elizabeth prides herself on being thorough and always explains everything to both the students and parents in language they can understand.
Two weeks ago, Elizabeth had an experience that upset her, and she is not sure what to do about it. A young student, Max Diaz, had met Elizabeth for his speech and language pathology evaluation at Richards Elementary School. Max has an expressive language disorder, and Elizabeth felt strongly that he would benefit from an augmentative communication device. She has used these devices in the past and has seen great success with them. Elizabeth has her quarterly supervision meeting with Michael Leary, the school principal, that afternoon. She talks about Max in the meeting because she is intrigued by his case. She tells Principal Leary her evaluation results and that she will be recommending the augmentative device. Principal Leary tells Elizabeth “Please do not put that recommendation in your written report. Max’s mother has not been overly involved in advocating for his needs. If we can hold off on meeting with her for Max’s education plan until the end of the school year, I won’t have to buy the device until the next academic year. Those devices are really expensive, and I don’t know if we have the money right now. Besides, who knows if it will really even work for him, given English is his second language.” Elizabeth leaves the meeting feeling uncomfortable.
The speech and language pathology evaluation report was completed and submitted to the administration. Elizabeth did include the recommendation for the augmentative device in the report because she knew that it was in Max’s best interest. She was eager to train Max in how to use this type of device. All that was needed now was administrative and parental approval. As soon as the individualized education plan (IEP) could be scheduled, they could move forward. A copy was sent to Principal Leary, Max’s homeroom teacher, and his mom, and one was placed in his academic record in the administrative office.
Several weeks later, Elizabeth asks Principal Leary when Max’s IEP is going to take place. She wants to get his mother’s and the team’s approval to move forward with various interventions, including the augmentative device. He tells her that Melinda, Max’s mom, has been slow to respond to the school’s request for a meeting, saying “We offered her a date, but she could not make it. Since then we have not been able to coordinate with a Spanish interpreter. I may just try to schedule her without one. Actually, the longer it is put off, the better, as we won’t have to bear the cost of the device you recommended on this year’s school budget.”
Knowing that the longer the meeting took to arrange, the longer Max would go without service, she wanted to say, “Aren’t you going to follow up and encourage her to get in soon?” but she didn’t. She knew Principal Leary would have to schedule the meeting and was also was afraid he may have been insulted by such a question.
Today, 3 months after the evaluation was completed, Elizabeth is walking another student to the after school program when she sees Max with his mom, Melinda Diaz, in the corridor. Melinda says, “Oh you must be the speech therapist. Thanks for the papers you sent to me about Max. It’s too bad that you and the teacher couldn’t meet a couple months ago. I was looking forward to talking with you all. I can’t read English that well so I had a hard time understanding the papers.”
“Oh. Did Principal Leary talk with you about setting another meeting time sooner rather than later?” Elizabeth asks, feeling tense.
“No, he didn’t. He just keeps saying, ‘Don’t worry.’”
“Well,” Elizabeth says, “You have the right to set another meeting time sooner rather than later and to have an interpreter there if you want to.”
Melinda immediately looks concerned. Elizabeth wants to say something to reassure her, but the words fail her. The school bell rings, and Elizabeth says a hurried goodbye. She feels a gnawing in the pit of her stomach, but she cannot immediately figure out what, if anything, she should do next.
That Elizabeth Kim is distressed is not surprising because something definitely is wrong. In fact, we might wonder about a health professional who felt no emotion at all about this situation: a young child with a learning disorder who is not performing to his potential and communication between his mother and the school staff appears to have broken down. Maybe Elizabeth has said too much—or too little—to help this family and school, both of whom have had some difficult discussions to confront. She is not sure how far she should go in advocating for her client and taking on the system.
Reflection
What is the caring, morally responsible action in this type of situation?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
We return to this story throughout the chapter, so keep your response in mind.
Ethical reasoning: a guide for ethical reflection
Clinical reasoning
As a health professional, you must learn to blend your knowledge, skills, and attitudes in response to varying clinical situations that require your professional judgment.2 As you have read in the previous chapters, being a health professional means you must learn to be responsible for your actions on others, both clients and the public. So, before we highlight theoretical parts of ethical study that take you deeper into addressing situations, we must discuss clinical reasoning. You may be familiar with the terms critical thinking or practical reasoning. These terms are similar to clinical reasoning.
Clinical reasoning is the complex thought process that health professionals use during therapeutic interactions. Schell defines this process well by stating that clinical reasoning is used by practitioners to “plan, direct, perform and reflect on [client] care.”3 Most significantly, clinical reasoning is used to guide action. Health professionals use clinical reasoning to analyze and synthesize information that they have gathered in the care of a patient.
You have likely already been trained to develop your clinical reasoning. Throughout your educational process, has a professor, clinical instructor, or supervisor ever asked you “why” when you gave an answer to a clinical question? If so, they are trying to understand your reasoning. They want to ensure that you not only know the answer to the question but that you have thought about and analyzed the situation from a broad perspective. The process of clinical reasoning is important because it guides your decision making in the care of the patient. The more complex the clinical case, the more demands placed on your reasoning.
Modes of reasoning
Health professionals use different modes of reasoning in response to particular features of a clinical case (Table 4-1). Many modes of clinical reasoning are used simultaneously to solve a clinical problem. For a caring response to be actualized, health professionals must use clinical reasoning to ensure that their decisions have meaning for the client. At various points in your clinical practice, you should stop and ask yourself, “Why am I doing what I am doing?” This helps you reflect on your clinical reasoning. Your reasoning is one of the strongest foundations you can have as a professional. It must continue to grow throughout your career to meet the demands and challenges of our ever-changing patient population and service delivery environment.
Table 4-1
| Forms of Clinical Reasoning | Description |
| Scientific Reasoning | A framework for understanding the condition of the patient. Involves the use of scientific methods such as hypothesis testing, cue and pattern identification, and evidence as related to a diagnosis. Scientific reasoning includes both diagnostic and procedural reasoning. The focus is generally on the diagnosis, procedures, and interventions for a specific condition. Data are systematically gathered, and knowledge is compared. |
| Narrative Reasoning | A framework for understanding the patient’s “life story” or illness experience. This type of reasoning helps clinicians make sense of the patient’s past, present, and future. Includes an appreciation of how his or her life story is influenced by culture, condition, and experiences. |
| Pragmatic Reasoning | A framework for consideration of the practical issues that impact care. Such issues include treatment environments, equipment, availability of resources (including training of individual providers), and other realities associated with service delivery. |
| Interactive Reasoning | A mode of reasoning that is used to help clinicians better interact with and understand their patient as a person. Highlights the interpersonal nature of the therapeutic relationship (e.g., the use of empathy, nonverbal communication, therapeutic use of self). |
| Conditional Reasoning | A blending of reasoning that involves the moment-to-moment treatment revision based on the patient’s current and future context. Used to anticipate outcomes over short or long periods of time. |
| Ethical Reasoning | A mode of reasoning used to recognize, analyze, and clarify ethical problems that arise. Helps clinicians make decisions regarding the right thing to do in a particular case. The moral basis for professional behaviors and actions. The focus is not on what could be done for the patient, rather on what should be done. |
Adapted from Schell and Schell (2008), Mattingly and Fleming (1994), and Leicht and Dickerson (2001).4–6
Ethical reasoning
Ethical reasoning is a key component of clinical reasoning. It is about norms and values and ideas of right and wrong. You use ethical reasoning when you ask yourself, “What is the morally correct action to take for this client?” Ethical reasoning helps guide the provision of professional care with an emphasis primarily on conduct. When you recognize the morally significant features of a clinical scenario, you are using your ethical reasoning. Ethical reasoning requires that you be able to gather relevant information and correctly apply your ethical knowledge and skills in the process of ethical reflection. This requires great attention to the details of each case.7 Ethical reasoning is not only concerned with recognizing, gathering, and applying ethical knowledge but also emphasizes the process one goes through when reasoning about the situation. We successfully engage ethical reasoning when we not only recognize that x is good and y is bad but when we articulate reasons for why x is good and y is bad.8 Some theories and approaches to ethics today use modes of reasoning outlined in Table 4-1 (e.g., narrative or interactive reasoning) that complement strictly ethical reasoning. Even the theories that focus mostly on character traits, narratives, or relationships must be reflected on. More will be said about this as the chapter unfolds.
Summary
Clinical reasoning requires that you be able to gather relevant information and correctly apply your knowledge and skills in a way that meets your desired goal of a caring response.
Metaethics and normative ethics
The ethical theories and approaches you will use for situations like that with Elizabeth Kim and Max Diaz fall within the dimension of ethics called normative ethics. Almost all the ethical reflection you do relevant to everyday life problems is in the area of normative ethics, so several approaches and theories are described in detail in this chapter. However, each theory also is part of a larger approach called metaethics. Metaethics tries to discover the nature and meaning of ethical reasons we propose as valid for making judgments about morality. How do we know whether there are ultimate truths about morality? Does the certainty about what Elizabeth Kim should do come from lived experience? From revelation or Scripture? From reasoning? Is there a “natural law” from which humans can discern truths about right or wrong? These are just some questions with which metaethics deals. An understanding of metaethics requires that you become more aware of your beliefs—religious, philosophic, what you have been taught or told—to recognize that they influence you regarding what is right or wrong, virtuous or blameworthy, whenever you face a situation with troubling ethical issues.
Normative ethics asks more concrete questions related to morality. When you assessed the situation described earlier in this chapter, you were using the concepts of normative ethics if you wondered, what would be an appropriate expression of care toward Max and Melinda Diaz? What types of acts are morally right or wrong and therefore should be considered in this case? What are the morally praiseworthy or blameworthy character traits (virtues) needed for the individuals or institutions involved in this story to arrive at a caring response? What values are morally good or bad for the harmonious functioning of this group of individuals? Your encounters with real situations involving patients, colleagues, other people, rules, policies, or practices are what will motivate you to engage in normative ethical reflection and ethical problem solving.
Summary
Normative theories and approaches deal with methods for ascertaining right and wrong actions and morally praiseworthy or blameworthy attitudes and behavior. Metaethics deals with the source of the reasons we give for our positions. Acquaintance with metaethics helps you gain insight into your own and others’ basis for moral judgments.
The caring response: using theories and approaches to guide you
You have already learned that the goal of your ethical deliberation is to answer the question: “What does it mean to provide a caring response in this situation?” You have also learned that although you will be faced with legitimate competing loyalties as a health professional, your primary loyalty must always be patient centered. But all these insights beg for further description about how to actually arrive at the ethically appropriate caring response in a particular situation.
Several ethics theories and approaches are relevant to your work of putting together this caring response. Your ethics work differs from an academic philosopher’s because you must not only apply clear thinking to ethical problems, which a philosopher must do as you learned in Chapter 3, but also decide on purposive action. You will not use all the theories or approaches covered in this chapter for any one situation. Just as you need to select the correct tool for building anything, the same is true for the tools we are describing.
The first two types, story or case-driven approaches and virtue theories, emphasize the importance of the kind of person you should strive to be (i.e., your attitudes and dispositions), so that you are well positioned to enact a caring response. Taken together, the several varieties share the common themes of paying attention to the details of stories for their moral content, becoming aware of one’s emotions in relation to what is happening in the story, and development of character traits that allow one to be prepared to act in a caring manner. Collectively, they also stress the moral relevance of relationships, both between individuals and with the institutional structures of society.
The last three approaches and theories, principle-based approaches, deontologic theories, and teleologic theories, are geared to forms of ethical conduct itself. Principle-based approaches have been developed to help people understand general action guides for ethical behavior, some of which are related to duties or rights, others related to consequences. Regarding deontologic and teleologic theories, these mouthfuls can be broken down into more digestible pieces by looking at their roots: the root word “deonto” means duty; the root word “telos” means end. Already you can see a distinction developing. Deontologic theories delineate duties (actually duties, rights, or other forms of action), whereas teleologic ones rely on an assessment of the ends or consequences to determine right or wrong. You have heard the expression, “Do the ends justify the means?” Deontologists would say “no”; teleologists would say “yes.” As noted previously, some principles guide you toward duty, others toward the “telos” or consequences. Are you ready to delve into these five theories or approaches in more detail?
Story or case approaches
In professional ethics, the story is the inevitable beginning point of ethical reflection because you encounter ethical problems in everyday life with everyday patients (or others). In story or case approaches, the assumption is that morally relevant information is embedded in the story.
In professional ethics, you also are equipped with foundation stones of ethical codes, a tradition, and societal expectations of how you will respond to legitimate requests for your professional services. Therefore, although the appropriate starting place for ethical analysis is the story, there are standards, principles, and other moral guides against which your opinion must be tested when you are deciding on a caring response. It is not simply, “You hold your view and I hold mine and they are on equal footing, morally speaking.” Therefore, professional ethics also is foundationalist based by nature.
Narrative approaches
Narrative is the technical term applied to the story’s characters, events, and ordering of events (e.g., the plot), although in health care ethics and legal circles you will more often see the term “case.” Narrative approaches are based on the observation that humans pass on information, impute and explore meaning in theirs and others’ lives, commemorate and celebrate, denounce, clarify, get affirmation, and, overall, become a part of a community through the hearing and telling of stories. Stories help us make sense of experiences. They are passed down from generation to generation among families or whole communities.9 Sometimes, the stories have been fictionalized in novels, poems, plays, songs, or other literary forms. Narrative ethicists conclude that good moral judgment must rely on the analysis and understanding of narratives. Kathyrn Hunter, a contemporary leader in narrative approaches to ethics within health care, reiterates this point, noting that through narratives:
“[W]e spin and untangle explanatory accounts of the way the world works and how we and our fellow human beings act in every conceivable circumstance. Memories of the past and ideas of the future are expressed in narrative accounts of how the world was and how it will, or should, become.”9
Her emphasis on “should” underscores the narrative ethicists’ position that future moral choices of individuals and communities are shaped through understanding and taking seriously the information and lessons embedded in stories.
Elizabeth Kim’s situation is revealed to you as a narrative. One thing probably disturbing to her is the fragmented narrative she herself has received. She lacks certain information about the student’s mother, the principal, and their exchanges that she would need to be confident of the moral challenges in the situation. This means that she is not only without all the facts and details but may feel she lacks pertinent information to make a valid ethical judgment about the real significance and meaning of the events unfolding before her. From the standpoint of ethical problems, Elizabeth is in a situation of moral distress.
Narrative approaches also highlight that in complex situations, there is not just one but several accounts. Suppose this story simply was titled “The Story of Principal Leary.” What different concerns might Principal Leary express regarding his role, his relationships with the student Max, Max’s mother (and all students and parents), and Elizabeth, or anything else? It may be a different story than the one told by Elizabeth. Or suppose this story was titled “The Story of Melinda Diaz.” Surely this mom’s account would include details about her personal life and experiences, her response to her son’s learning disability, and her hopes, dreams, and fears. These details would alter inexorably what Elizabeth’s story taken alone conveys. Narrative ethics approaches require your diligent effort to consider as many “voices” as possible before interpreting the situation for its moral significance.
Summary
Narrative ethics requires attention to the details of the story and that all voices be considered before the situation is assessed for its moral significance.
Related posts:
Surviving student life ethically
A six-step process of ethical decision making in arriving at a caring response
Communication and information sharing
The ethical goal of professional practice: a caring response
Professionals as good citizens: responsibility and opportunity
Ethical issues in end-of-life care
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
