Documente Academic
Documente Profesional
Documente Cultură
RIVKA GRUNDSTEIN-AMADO
Key words: decision making process, ethical clinical decision making models, medical
ethics, moral thought process, organizational structure, professional-patient relationship,
value theory
1. INTRODUCTION
deductive, and begins with a particular value judgment, one that is rooted in the
various ethical principles that are grounded in ethical theory [6]. It is important
to note that it is my intention to introduce merely the basic concept of a moral
reasoning structure and not to discuss in details the existing sophisticated
literature around ethical principles and theories.
The moral reasoning structure starts with the identification and elicitation of
the individual value system. Values can be perceived as an internal code or
standard arising from human needs. Kluckhohn [7] maintains that value implies
a persistent internalized code or standard of action. Moral reasoning, then,
involves an internal mechanism that enables individuals to distinguish between
right and wrong, good and bad.
A value is a conception, explicit or implicit, distinctive of an individual or characteristic
of a group, of the desirable which influences the selection from available modes, means,
and ends of action ([7], p. 395).
The second component of the model is the procedural schema which lists eight
steps that need to be taken in making an ethical decision. The eight categories
imply that ethical decision making is a process consisting of progressive
dynamic functions, leading the individual decision maker to reach a desirable
choice. The eight categories are as follows:
A. Problem perception.
(i) Identification of the ethical problem.
(ii) Identification of the medical problem.
B. Information processing.
(i) Gathering medical-technical information.
(ii) Seeking other sources of information.
C. Identification of the patient preferences.
D. Identification of the ethical issues.
E. Listing the alternatives.
F. Listing the consequences.
G. The choice.
H. Justification.
The four main steps of the procedural schema are based on classical decision
making theory which has focused chiefly upon rational, logical decisions that
are made through the definition of the issue, through analysis of the existing
situation, through identification of all possible alternatives and consequences,
and through subsequent evaluation of all of these [16]. The distinction between
the ethical component and the medical component can help professionals to
understand the very nature of the ethical problem. Such distinction enables
individuals decision makers to be aware of other aspects of the problem. This is
supported by Elstein's claim that in the course of making clinical decisions
professionals may omit certain aspects of the problem. This may lead to
different representations of the problem resulting in a different decision outcome
[17].
Simon in his book Administrative Behavior [16] focusses on the process of
choosing from among alternatives. This process leads to a selection of a
particular course of action. Simon asserts that decisions contain factual and
ethical content. The factual is a descriptive mode of actions and can be proven to
be true or false. The ethical has an imperative qualitative dimension, which
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means that in the final analysis the option that is the most preferable or desirable
is chosen over another. The final course of action results from the calculation
and delineation of alternatives and ultimately the selection of one option to the
exclusion of the others. The individual decision makers are bounded by their
rationality and cannot anticipate all of the consequences of their actions. The
limitations of knowledge, personal experience, habits, cognitive ability, and the
value-religious system of the decision maker become obstacles in reaching a
rational decision [16]. Increasing the knowledge that influences the generation
of alternatives and consequences might overcome, to a certain degree, the
limitations that bound the rational process.
March and Simon, suggest a different approach to decision making by
proposing a strategy of 'satisfying': "Most human decision making, whether
individual or organizational, is concerned with the discovery and selection of
satisfactory alternatives" ([18], p. 140). As well, they make a distinction
between the optimal and the satisfactory. In the optimal situation the decision
maker is assumed to have all the alternatives against which to apply the criteria,
whereas in a satisfactory situation the decision maker applies the criteria to a
few satisfactory alternatives considered good enough to meet the desirable
objective [19].
Similarly, Wilson and Alexis claim that the individual decision maker starts
with ideal goals that coincide with his or her 'aspiration level'. The aspiration
level can be seen in terms of the general motives, needs, and values the decision
maker possesses. Then, the decision maker engages in a search activity that
involves delineating a limited number of alternatives and consequences and
thereafter searching for a satisfactory solution among these limited alternatives
[20]. Consequently, the decision maker's level of aspiration is instrumental in
determining whether a satisfying alternative exists among those already
available.
Hodgkinson develops further the role of values, motives and aspirations in the
process of decision making. Values are defined as "concepts of the desirable
with motivating force" ([21], p. 120). He emphasizes the value notion by
claiming that: "the intrusion of values into the decision making process is not
merely inevitable, it is the very substance of the decision" ([21], p. 55).
Moreover, he continues to assert that "the presence of an internal value com-
ponent ... in the decision making process assures the process of a philosophical
status" ([21], p. 64). Value knowledge is an integral part of professional
competence. Additionally, he, like Simon, contends that decisions are not made
in isolation or in a vacuum. Decisions are made within a context; they are
constrained by environmental influences.
CLINICAL-ETHICALDECISIONMAKING 163
The third component of the model comprises the contextual element that affects
the ethical decision making process, that is, the decision maker's relationship
with the client (i.e. the patient) and the organizational structure (i.e. the health
care system). Both contexts impose various constraints on the individual
decision maker and eventually influence the final course of action.
The encounter between patient and HCPs may be characterized as the focus of
the entire health-care enterprise. The relationship between HCPs and patients is
the place where the interest of the patient is created with reference to the totality
of medical discourse [22]. HCPs and the patients share the burden of ethical
clinical decisions. Together they are involved in constant interaction in which
they transform their experiences in order to achieve the best decisions.
The literature has developed various models of HCP-patient relationships, and
each incorporates some important ethical elements. The basic issue that
underlies the relationship is the relative knowledge and power of the involved
parties. There are different approaches with regard to how the HCPs interpret
their relationship with the patient. One mode of interpretation is the paternalistic
mode. Conceptually, paternalism refers to the idea of limiting the individual
autonomy by others, for the promotion and protection of individual well-being
and avoidance of harm. It contains two features: one is beneficence, that which
benefits the other person, and the other is the refusal in some circumstances to
accept that person's choices and actions ([23], p. 12). If this is the prevailing
pattern the HCPs instruct the patient to follow or submit to a course of treatment
and the patient co-operates to the extent that he/she obeys. The HCPs provide
health care to the best of their ability and consistent with what they believe will
be in the patient's best interest. The paternalistic model assigns moral authority
and discretion to the HCPs because good health is assumed to be a shared value,
and because the HCPs' competence places them in a position in which they are
obliged to help the patient recover and get better [24].
The second mode is one of participatory, shared decision making. This model
stresses the notion that the HCPs and the patient are partners in the pursuit of the
shared value and goal of health. It emphasizes the mutual contribution of both
parties. The HCPs help the patients to help themselves, while the patients use
expert help to realize their (and the HCPs') ends [24]. In this mode the HCPs do
not describe a priori what is best for the patient. The search is mutual. This
becomes the essence of the relationship.
The third mode is that of advocacy. This model grants the patients a
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decisional authority. The health team provides information, advice and guidance
to the patient, and consequently enables the patient to make an ethical decision
in a constructive manner. The patient's needs, wishes, preferences and ideals are
the major criterion in making the final choice. The HCPs follow the patient's
interests and genuinely probe the cues the patient presents about the nature of
the problem. In cases when the patient indicates that he/she cannot follow the
HCPs' line of reasoning, they will try another approach [25]. It should be noted
that, the participatory and the advocacy modes incorporate certain hermeneutical
aspects, such as those which propose a dialectical relationship between the
explanatory powers of science and the need for these explanations to be
modified by and understood through the patients' own terms and context [26].
The ethical decision making process occurs in a general context as well, that is,
in the health care system. The HCPs interact with the organization, which is
generally bureaucratic and hierarchical and imposes a considerable restriction on
the individual decisional autonomy. The external structure includes the division
of work, standards, procedures and policy guidelines, the line of authority, and
the communication system [27].
The most fundamental given through which the organization set limits on the
decisional context of the individual decision makers is in the division of work.
The individuals' thought processes are limited and directed and their scope
becomes narrow and restricted. Thus, the creative endeavor involved in the
exercise of personal moral judgment becomes hampered, as does the in-
dividuals' ability to move towards a more inclusive perspective with regards to a
particular ethical problem.
Standards, procedures or policy guidelines limit the individuals' action by
imposing restrictions to which the individual must adhere. Policy guidelines and
rules become the guiding criteria for making ethical decisions.
The line of command or structure of authority is another important strategy by
means of which the organization is able to continue functioning. Decision
making power is delegated through an hierarchical ladder. This imperative tool
affects and controls the ethical practice of health professionals.
The last factor affecting the ethical decision making process is the way in
which information is communicated. The more information there is, and the
better the system of communication itself, the easier it will be to clarify
problems, solutions, and consequences.
All the above-mentioned organizational constraints can to an extent, serve as
an impediment to the decision making process in particular, and to organiza-
tional effectiveness in general. However, these constraints may also create
CLINICAL-ETHICALDECISIONMAKING 165
change and fluidity within the organization and might serve as an external
device for shaping the world as one might wish it to be shaped [28],
Within the health-care system, there are several modes of care delivery:
individual care, community care and institutional care. The hospital itself is an
institutional setting with a highly stratified occupational structure containing two
main hierarchies of authority: the administrative and the clinical. There is also a
third locus of authority: the board of directors whose legal responsibility applies
to the hospital as a whole [29].
The administration is accountable to the board of directors, and neither
directly determines the HCPs' practice. At the same time, the HCPs are bound
by their dependence on the hospital and by its budgetary and organizational
restrictions. For example, the nurses are bound by their employer (i.e. the
hospital administration), by the doctors who order the treatment, and by the
patients who require care.
Practically, the organization limits nurses' power to fulfill their values and
ideals; this accordingly influences their capacity to act as moral agents. The
physicians are evidently in a different position having greater autonomy, but
they are prone to fail in their moral practice due to external pressures coming
from the consumer movement, malpractice suits, and formal institutional rules
which limit their scope of action.
To sum up, ethical decision making can be perceived as a single comprehen-
sive process encompassing two Oisciplines, ethics and decision making theory.
These two disciplines are integrated and unified as part of a complementary
process in which ethics are used as a systematic tool brings to bear and em-
phasize the positive aspects of the decision making process. The integrated
structure which results is affected by vankms relational modes of interaction.
The HCPs have the obligation to safeguard the panem's moral rights and to
provide appropriate care, and the patient needs in turn, to accept, negotiate or
refuse the proposed treatment. This dynamic process is an integral part of a
larger entity - the organization itself, which affects HCPs' practice by imposing
the various, diverse forces that regulate or limit action.
A review of four existing models in the literature outlines their strengths and
weaknesses with respect to the three frames of content mentioned above (i.e.,
the ethical component, the decision theory component, the contextual com-
ponent).
The first model to be reviewed is a 'clinical model for decision making'
developed by Martin [1]. It proposes a reflective analytical method as the
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they would list only the feasible rights, duties, rules and principles independent
of their consequences.
6. CONCLUSION
REFERENCES