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AN INTEGRATIVE MODEL OF

CLINICAL-ETHICAL DECISION MAKING

RIVKA GRUNDSTEIN-AMADO

Department of Psychiatry, Baycrest Centre for Geriatric Care, 3560


Bathurst Street, North York, Ontario M6A 2E1, Canada

ABSTRACT. The purpose of this paper is to propose a model of clinical-ethical decision


making which will assist the health care professional to arrive at an ethically defensible
judgment. The model highlights the integration between ethics and decision making,
whereby ethics as a systematic analytic tool bring to bear the positive aspects of the
decision making process. The model is composed of three major elements. The ethical
component, the decision making component and the contextual component. The latter
incorporates the relational aspects between the provider and the patient and the organiza-
tional structure. The model suggests that in order to arrive at an ethically, justifiable
sound decision one make reference to those three elements.

Key words: decision making process, ethical clinical decision making models, medical
ethics, moral thought process, organizational structure, professional-patient relationship,
value theory

1. INTRODUCTION

The study of ethical decision making in a health-care system is undertaken to


enable health professionals to increase their awareness of ethical issues involved
in their practice and to guide them in arriving at sound, justifiable decisions. The
basic assumption of this paper is that ethical decisions will be better made if
they are not habitual or hasty ones but rather are based on a systematic analysis
or method.
There are several benefits of approaching clinical-ethical decisions through a
systematic sequential method. A model enables the individual decision makers
to ascribe ethical validity to their statements. A statement that is subjected to a
rigorous analytic thought process can be a better guide to action than one based
on intuition or blind adherence to pre-existing rules. Through a model of this
kind the individuals can clarify the nature of the ethical problem, search for
other sources of information, and enhance justification of the chosen course o f
action. Furthermore, the model can prompt the individual decision makers to
enlarge their conceptual space beyond their past experience and, consequently,
develop a meaningful understanding of new concepts o f which they may not

Theoretical Medicine 12: 157-170, 1991.


© 1991 Kluwer Academic Publishers. Printed in the Netherlands.
15 8 RIVKAGRUNDSTEIN-AMADO

have been aware.


Several strategies for making ethical decisions are reported in the literature
[1-4]. All of these serve to expand the health care providers' thinking about
moral issues and each emphasizes different aspects of ethical decision making.
However, they fail to recognize two essential features that are imperative for the
attainment of a desirable moral end. First, the organizational component as a
necessary frame of reference needs to be considered while making a clinical
ethical decision. Second, ethics and decision making are integrated into a
synergistic complementary process. Furthermore, these existing models for
making ethical clinical decisions have not been empirically tested.
The purpose of this paper is foremost to propose a model of clinical-ethical
decision making that will assist the health care professionals (HCPs) to arrive at
a sound, defensible judgment. The paper will then review four existing models
in the literature and will demonstrate their major characteristics and their
deficiencies in the light of the proposed model. It should be noted that in
contrast to previous-practice models, this model has been tested in two hospital
settings with eighteen HCPs (i.e., nine nurses and nine doctors) [5]. This
provides some evidence as to the viability of the model and its practical use in
dealing with clinical-ethical problems in a concrete case situation.
The model I am about to propose involves two underlying assumptions: first,
decision making is a process of choice leading to action, and both are influenced
by context and content. The context includes the HCPs' relationship with the
patient, organizational constraints, and possibilities for the decision makers'
personal fufillment. The content refers to the specific details of a particular case.
Second, action is an expression of the decision makers' personal, cultural, and
religious values, mad of their ideological position, which is justified through a
process of appealing to ethical principles and theories. This justification process
provides the decision makers with the means for advocating their decisions and
ascribing ethical validity to their choices.
The model is composed of three major elements: the ethical component, the
decision theory component, and the contextual component that comprises the
relational aspects between the provider and the patient and the organizational
structure. The model suggests that in order to arrive at an ethically justifiable,
sound decision reference can be made to these three elements or frames of
content.

2. THE ETHICAL FRAMEWORK

The ethical framework of the health care professional is determined by the


individual moral reasoning structure. Ethical reasoning is hierarchical and
CLINICAL-ETHICALDECISIONMAKING 159

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).

Accordingly, values contain both an affective and a cognitive dimension.


Kluckhohn incorporates reason and feeling into the value notion. The combina-
tion of "conception" with "desirable" generates a complementary basis of reason
and feeling. Similarly, Callahan maintains that "emotions and thinking are
complementary, synergistic, parallel processes constantly blending and interact-
ing as a person functions" ([8], p. 10), and consequently the person selects one
course of action over the other. Kluckhohn and Strodtbeck also support this
view and they claim that values merge affect and concept. Values contain
cognitive, affectional and directional aspects and they serve as criteria for
judgment, preference and choice, and thus constitute grounds for decision
making ([9], p. 5).
Another view of values perceives them as a system, an organized set of
preferential standards that are used in the making of selections of objects and
actions. Values provide direction in resolving conflicts, in invoking social
sanctions, and in coping with needs or claims for social and psychological
defenses of choices made or proposed ([10], p. 20). Similarly, Beck claims that
values are ordered within a system that provides the frame for their interactive
ongoing relationship [ 11 ].
Additionally, values can be seen as an expression of human needs, and as
such they create a specific mode of conduct or end-state of existence ([10], p. 5).
Beck also maintains that values are grounded in basic human needs. A fairly
common set of universal values thus exists, since individuals have similar needs
[11]. Those values common to a large group of people can be established as
rules and norms. For example, the value of 'respect for others' and 'self respect',
identified by Beck as among the basic human values, are established as ethical
rules in the Western societies. The other basic human values that Beck identifies
include survival, happiness, companionship, friendship, helping others (to an
160 RIVKAGRUNDSTEIN-AMADO

extent), participating in a community, knowledge, freedom, and a sense of


meaning in life [11]. Beck claims that the concept of 'universal values' provides
a common basis for value inquiry. Basic human values are interconnected and
also form part of a larger value system that includes moral values, social and
political values, intermediate-range values, and specific values. According to
Beck, values are not absolute, but rather are interconnected within a system;
every value is both a means and an end [12].
To sum up, values may be seen to exist in an ordered system. They are
interconnected, they are changeable, and they carry a sense of fluidity. They
serve as an internal mechanism that filters conflicting stimuli. They are linked to
needs and thereby help the individual to formulate a standard of what is
acceptable and appropriate action and to determine finally the ultimate course of
action.
Value theory, as a foundation of basic human values, generates three main
ethical principles: the principle of beneficence, the principle of autonomy, and
the principle of justice.
The principle of beneficence refers to an obligation to secure the well-being
of individuals [13]. Physicians need to exercise their own discretion in order to
safeguard the patients' needs. Generally speaking, beneficence requires the
balancing of benefits and harms [6].
The principle of autonomy requires that one recognize both the patients' right
to have a major say in decisions affecting them and the physician's obligation to
respect and enhance that right. An autonomous person is an individual who is
capable of making a deliberate choice, of refusing or accepting any medical
intervention. This principle promotes individuals' involvement in decisions
affecting their well-being, and involves their fundamental human values. The
principle of autonomy encompasses two elements: respect for wishes and
respect for rights. Being responsive to the patients' wishes is not identical to
acknowledging the patients' rights.
The principle of justice has been given many interpretations in the literature.
Basically, it refers to the fundamental equality of human beings: every in-
dividual deserves equal respect and equal consideration [14]. John Rawls'
central conception of justice expresses itself in terms of fairness and economic
distribution. Justice requires a fair distribution of burdens and benefits. This can
be achieved through communal efforts to promote the good of all society's
members [15]. Justice might be seen as most closely linked to harmony and
balance. It demands a global perspective on the concerns of a large number of
people and seeks an overall harmony among these concerns.
All of these ethical principles can be implemented by combining two major
ethical theories concerned with the determination of fight and wrong actions: the
telological and the deontological. The former holds that the worth of an action is
CLINICAL-ETHICALDECISIONMAKING 161

determined by its consequences. In contrast, the latter approach considers the


nature of the act itself and the relevant principles and duties.

3. THE DECISION THEORY COMPONENT

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
162 RIVKAGRUNDSTEIN-AMADO

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

4. THE CONTEXTUAL COMPONENT

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.

4.1. The Relational Context

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
164 RIVKAGRUNDSTEIN-AMADO

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].

4.2. The Organizational Context

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.

5. REVIEW OF EXISTING MODELS OF CLINICAL ETHICAL DECISION MAKING

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
166 RIVKAGRUNDSTEIN-AMADO

appropriate means of making ethical decisions in a given medical situation.


Martin's model consists of four basic dimensions. First, the purpose of ethical
analysis is to provide the means by which the decision makers' ideals can be
fulfilled in action. Second, the optimal decision is one which is appropriate for
both the patient and the physician. Decision making is an interactive process
between the health professional and the patient. The patient brings his own
values, such as personal ideology and interests, and also factual elements, such
as symptoms, signs, history, etc, which are significant for the decision making
process. The professionals bring their rational ability, special technical-scientific
skills and a certain value structure, which enable them to interact with the data
provided and select the responsible and appropriate course of action.
The third aspect of the model is the reflective mode. By this process the
decision makers determine whether their intentions are being realized or their
decisions need to be reconsidered. This process is based once again on the
assumption that decisions should be responsive to both context and moral ideals.
The fourth aspect of the model is the one in which ethicists help in providing
a more accurate understanding of the issues and possibilities for decisions and
action. They help to clarify what the physicians' value system is like and
provide a means of systematically assessing its adequacy for fulfilling their
moral ideal. Consequently physicians and ethicists can jointly accomplish their
common goal, namely the well-being of the patient.
Martin's model strengthens the reflective-cognitive element in the decision
making process. He places emphasis on the application of epistemological skills
in order to contribute meaning and significance to the clinical data and also on
the importance of understanding one's own values in order to reach a respon-
sible and appropriate decision in a given situation. However, the weakness of the
model is that it neither incorporates any specific step-wise procedure for making
the actual decision nor suggests at which stage of the decision making process
the ethicist should perform his role. Additionally, the model ignores the
integrative element between ethics and decision making.
The second model to be examined is Siegler's model [2], that offers a
systematic approach to clinical-ethical decisions. It involves four categories into
which most considerations in a clinical case can be placed. These categories are:
the medical indication in the case, such as diagnosis, prognosis, risks and
benefits of various treatments; the patient's preferences; quality of life considera-
tions; and external factors, such as the wishes and needs of the patient's family,
the costs of medical care, the allocation of medical resources, the research and
teaching needs of medicine and the safety and well-being of society. The last
two considerations will be invoked in a clinical situation when the patient is
incompetent to make an informed decision or when the medical indications are
limited (e.g. untreatable illnesses). However, while this decision making
CLINICAL-ETHICALDECISIONMAKING 167

approach emphasizes the technical component in the decision and the


preferences of the patient, it disregards the need for a comprehensive ethical
analysis of a particular bioethical problem. Additionally, no structure is offered
to suggest how to reach a sound decision. No regards has been given to the
organizational component as part of the external factors that might influence the
decision making process. This approach embodies the view that ethical deci-
sions are to be made solely by physicians and patients, without their sharing the
decision with other professionals. Furthermore, no suggestion has been offered
to resolve a potential conflict that may arise between the different categories.
For example, the preferences of the patient might conflict with external con-
siderations such as the high costs of a specific medical treatment.
The third model to be reviewed is that developed by Candee and Puka [3].
The model outlines two classical orientations in moral philosophy - teleology
and deontology - which might be used to resolve a bioethical problem. Both
approaches strive to be systematic and internally consistent, but they approach
the ethical problem from different perspectives. The steps that Candee and Puka
suggest for the moral reasoning process are as follows. The teleological
approach, gathers general information; lists relevant alternatives; predicts the
consequences of each alternative; determines probability of each outcome
occurring; assigns value to each outcome; and determines utilities. The deon-
tological approach, gathers general information; lists relevant alternatives; lists
relevant rights-claims, duties and principles; establishes the validity of rights-
claims; and determines priorities between the listed rights, duties and principles,
and balance claims.
Both teleology and deontology suggest a way in which the individual decision
makers may systematically reflect in the course of making ethical decisions. The
decision making process thus became organized into an ordered series of steps
whose function is to offer assistance in arriving at a decision. In contrast to the
previous models, Candee and Puka offer a way of reaching a decision through
the systematic application of a valid ethical approach. This kind of model
increases the possibility that decision makers could tailor their own values to the
best interests of the client.
The weaknesses of this model manifests itself in several areas. It doesn't
show how to choose between telological and deontological approaches [30]; it
suggests a quantitative approach for reaching an optimal course of action,
whereas some elements in the decision making process are not amenable to
quantification and are inaccessible to the decision maker due to time and cost
constraints [19]; no account is given of how a clear definition of the ethical
problem could be achieved, nor is there any consideration of the ethical issues
involved in each particular case; and, it does not recognize the influence of
external factors such as organizational constraints, that might affect the process
168 RIVKAGRUNDSTEIN-AMADO

of reaching a sound ethical decision.


The fourth model has been developed by Pellegrino [4]. This model com-
prises two analytical structures: one substantive and one procedural. The
substantive structure consists of four conceptual dimensions that formulate the
moral choices of the decision makers. The procedural structure comprises five
steps that enable the individual decision maker to arrive at a final course of
action [4]. The four substantive issues in Pellegrino's model are: understanding
the philosophy of the physician-patient relationship; understanding the theory of
ethics, the various moral theories, and the principles that are common to clinical
ethical decisions; understanding the interpretation the physicians place on this
theoretical ground; and, identifying and recognizing the ultimate moral sources
of the health-care provider and the patient.
The procedural schema in the model involves a set of steps to be used in
making the decision itself. The five steps are as follows: establish the technical
facts of the specific problem; determine what is in the patient's best interests;
define the ethical issues and principles involved in the specific problem; state
ones decision in clear and concrete terms; and, justify the decision.
The major strength of this model lies in the fact that Pellegrino offers in his
procedural schema, a clear distinction between the medical facts and the ethical
elements in the decision making process, a distinction which can help prac-
titioners deal with the complexity of the process of medical ethical decision
making. Additionally, he recognizes the importance of combining the concep-
tual elements and the technical aspects of the decision making process in order
to reach the best course of action in a particular case.
However, this model, too, has its weaknesses. To begin with, it makes
reference only to physicians. Other health care professionals are not taken into
consideration. In the substantive part, the organizational context is not taken into
consideration. An action is the determination of both specific content and
general context. There is no reference to collaborative decision making between
HCPs and others who will be affected by the future course of action, such as the
family and society.
The deficiencies in the procedural part reside in two areas: the integrative
point between ethics and decision making is missing; and there is no indication
of a method for the formulation of the ethical problem and the determination of
a definite set of relevant alternatives. In the classical rational decision making
process, this element is essential to making a desirable choice [16]. The
procedural schema might differ depending on whether the decision makers
choose to follow the teleological approach or the deontological approach. For
example, after listing the alternative courses of action, according to the teleologi-
cal approach the decision makers should anticipate the consequences of each
alternative; but if decision makers choose to follow the deontological approach,
CLINICAL-ETHICALDECISIONMAKING 169

they would list only the feasible rights, duties, rules and principles independent
of their consequences.

6. CONCLUSION

In conclusion, my aim in this paper is to propose a new comprehensive model


that will address deficiencies in some of the previous practice-models proposed
for ethical-clinical decision making. The proposed model highlights the
inclusion of the organizational component as a necessary frame of reference for
making ethical decisions. The model suggests that in order to make a sound
responsible ethical decision one must make reference to ethics, decision making
and contextual elements. In addition, the model can be conceptualized as an
integrated structure composed of two major elements: ethics and decision
making. This integration can be seen as a complementary process whereby
ethics as a systematic tool provides the individuals decision makers with the
critical-reflective skills and the justification of the ultimate choice that are
lacking in the general decision making process. Ethics enhances the exploration
of new insights into problems and strengthens the search for new knowledge,
goals and alternative options. The search activity (i.e., the information process-
ing) is analogous to the whole notion of 'ethics', as a progressive attempt to
broaden one's horizons, to discover and explore hidden dimensions of the stated
problem. The employment of an integrative model can lead to clear thinking and
increased confidence in the justification of decisions. More importantly, the
model can serve as a vehicle that enables the individual to move from an
understanding of the self to an understanding of others.

REFERENCES

1. Martin A. A clinical model for decision making. J Med Ethics 1978;4:200-6.


2. Siegler M. Decision making strategy for clinical-ethical problems in medicine. Arch
Intern Med 1982;142:2178-9.
3. Candee D, Puka B. An analytic approach to resolving problems in medical ethics. J
Med Ethics I983;9/10:61-9.
4. Pellegrino ED. The anatomy of clinical ethical judgments in perinatology and
neonatology: a substantive and procedural framework. Semin Perinatot 1987;
11:202-9.
5. Grundstein-Amado R. Ethical Decision Making Processes in the Health Care
System. [Dissertation]. Toronto: University of Toronto, 1990.
6. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York:
Oxford University Press, 1989.
7. Kluckhohn C. Values and value-orientations in the theory of action: an exploration
in definition and classification. In: Parson T, Shils EA, eds. Toward A General
170 RIVKA GRUNDSTEIN-AMADO

Theory of Action. Cambridge, MA: Harvard University Press, 1951:388-433.


8. Callahan S. The role of emotions in ethical decision making. Hastings Cent Rep
1988;18:9-14.
9. Kluckhohn FR, Strodtbeck FL. Variations in Value Orientations. Evanston: Row,
Peterson and Company, 1961.
10. Rokeach M. The Nature of Human Values. New York: The Free Press, 1973.
11. Beck C. Educational Philosophy and Theory: An Introduction. Boston: Little
Brown and Company, 1974.
12. Beck C. The Nature of Values and Implications for Value Education, 1984
(unpublished manuscript).
13. Levine RJ. Ethics and Regulation of Clinical Research. Baltimore: Urban &
Schwarzenberg, 1986.
14. Jameton A. Nursing Practice: The Ethical Issues. New Jersey: Prentice-Hall, Inc,
1984.
15. Rawls J. A Theory of Justice. Cambridge MA: Harvard University Press, 1971.
16. Simon HA. The Administrative Behavior. New York: Free Press, 1957.
17. Elstein AS. Cognitive processes in clinical inference and decision making. In: Turk
DC, Salovey P, eds. Reasoning, Inference, and Judgment in Clinical Psychology.
New York: The Free Press, 1988:17-50.
18. March J, Simon H. Organizations. New York: John Wiley, Inc, 1958.
19. Harrison F. The Managerial Decision Making Process. Boston: Houghton Mifflin
Company, 1987.
20. Wilson C, Alexis M. Basic framework for decisions. Journal of the Academy of
Management 1962;5:20-5.
21. Hodgkinson C. Towards A Philosophy of Administration. Oxford: Basil Blackwell,
1978.
22. Broekman JM. The philosophical basis of medicine as a philosophical question.
Theor Med 1987;8:135-45.
23. Childress JF. Who Should Decide? Paternalism in Health Care. New York: Oxford
University Press, 1982.
24. Childress JF, Siegler M. Metaphors and models of doctor-patient relationships: their
implications for autonomy. Theor Med 1984;5:17-30.
25. Hoffmaster B, Weston W. The patient in the family and the family in the patient.
Theor Med 1987;8:321-32.
26. Lock JD. Some aspects of medical hermeneutics: the role of dialectic and narrative.
Theor M ed 1990; 11:41-9.
27. Mouzelis NP. Organisation and Bureaucracy. London: Routledge & Kegan Paul,
1985.
28. Perrow C. Complex Organizations. A Critical Essay. New York: Newbery Award
Records, Inc, 1986.
29. Eakin J. Hospital power structure and the democratization of hospital administration
in Quebec. Soc Sci Med 1984; 18:221-8.
30. Fletcher C. Commentary. J Med Ethics 1983;9:69-70.

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