Al-Rawda University College
Department of Nursing & Health Sciences
Bachelor of Science in Nursing
Fall 2024/2025
chapter 4 Ethical Decision-Making
Process
Course: Ethics and professionalism
Instructor: Mohammad Awwad, MSN, PhD
candidate, Nursing Program
OBJECTIVES OF THE SESSION
• Understand the ethical decision-making process: Learn the steps
involved in making ethical decisions in nursing practice.
• Explore factors affecting decision-making: Identify the internal
and external factors that influence how nurses make ethical decisions.
• Apply ethical decision-making models: Use frameworks to analyze
and resolve ethical dilemmas in nursing care.
ETHICAL DECISION-MAKING OVERVIEW
• Ethical decision-making is the process nurses use to address ethical
dilemmas by weighing moral principles, patient needs, and professional
obligations (Burkhardt & Nathaniel, 2020).
• Why it matters:
Nurses often face complex situations where the best course of action is
unclear, requiring a structured approach to arrive at ethical conclusions.
• Example: Deciding whether to continue aggressive treatment for a terminally ill
patient whose family is requesting everything be done despite the patient's prior
wishes.
STEPS IN ETHICAL DECISION-MAKING
• The ethical decision-making process involves several key steps to
ensure thorough consideration of all relevant factors.
• Identify the ethical issue
• Gather relevant information
• Evaluate the ethical principles involved
• Consider the possible alternatives
• Make a decision
• Implement the decision
• Evaluate the outcomes
STEP 1: IDENTIFY THE ETHICAL ISSUE
• Definition:
• Recognize that an ethical dilemma exists. Ethical issues typically arise when
there is a conflict between competing values or duties.
• Example: A patient wants to leave the hospital against medical advice, creating
a dilemma between respecting their autonomy and the nurse's duty to prevent
harm.
• Clarification:
Ethical dilemmas often involve tension between principles like autonomy
and beneficence. Identifying these tensions is crucial in the first step.
STEP 2: GATHER RELEVANT
INFORMATION
• Key Aspects:
• Gather all necessary information, including medical facts, patient
preferences, and institutional policies.
• Consider the perspectives of all stakeholders (e.g., the patient, family,
healthcare team).
• Example: Before making a decision about withholding treatment,
understand the patient's prognosis, their expressed wishes, and the
family's concerns.
• Clarification:
Thorough information gathering is essential because ethical decisions
often have profound consequences for patient care and well-being.
STEP 3: EVALUATE THE ETHICAL PRINCIPLES
INVOLVED
• Core Ethical Principles:
• Autonomy: Respecting the patient's right to make their own decisions.
• Beneficence: Acting in the best interest of the patient.
• Non-maleficence: Avoiding harm to the patient.
• Justice: Ensuring fairness and equality in care.
• Example: In end-of-life care, the nurse must balance the patient's autonomy
with beneficence (doing good) and non-maleficence (avoiding harm from
unnecessary interventions).
• Clarification:
This step requires critical thinking to prioritize which ethical principles
should guide the decision.
CONSIDER THE POSSIBLE ALTERNATIVES
• Explore all options:
Nurses must consider all possible actions that can be taken, including
doing nothing. Each option should be evaluated based on its alignment
with ethical principles and possible outcomes.
• Example: When dealing with a family conflict about continuing life support,
alternatives could include facilitating family meetings, seeking mediation,
or consulting an ethics committee.
• Clarification:
No single option is always right—this step encourages creativity and
critical thinking about what might be the best course of action
STEP 5: MAKE A DECISION
• Application:
After evaluating all options, the nurse must choose the course of action
that best aligns with ethical principles and patient well-being. This
decision should be based on sound reasoning and clear justification.
• Example: In a case of an unresponsive patient, after considering the
patient's advance directives and ethical principles, the nurse may decide to
follow the directive and not resuscitate, even if family members object.
• Clarification:
This step often involves collaboration with the healthcare team,
ensuring that everyone is aligned in the decision-making process.
STEP 6: IMPLEMENT THE DECISION
• Taking action:
Once the decision is made, it must be carried out in a way that ensures
the patient's dignity and well-being are respected.
• Example: In a decision to withhold life-sustaining treatment, the nurse
may need to explain the decision to the family and provide palliative care
to ensure the patient's comfort.
• Clarification:
Implementing the decision may require clear communication and
sensitivity, especially in emotionally charged situations.
STEP 7: EVALUATE THE OUTCOMES
• Reflect on the results:
After implementing the decision, nurses should reflect on the outcomes
and whether the desired ethical goals were achieved. This step also
involves assessing how the decision impacted the patient, family, and
healthcare team.
• Example: After a decision to discontinue treatment, the nurse should
evaluate whether the patient’s comfort was maintained and the family was
supported through the process.
• Clarification:
Evaluation helps nurses learn from their experiences and improve
future ethical decision-making.
FACTORS AFFECTING ETHICAL DECISION-MAKING
• Internal Factors:
• Personal values and beliefs: A nurse’s background and experiences influence how
they view ethical dilemmas.
• Moral distress: Nurses may experience emotional distress when they feel unable to
act on their ethical beliefs due to institutional constraints or patient/family wishes.
• External Factors:
• Institutional policies: Hospital policies can shape the options available to nurses in
ethical decision-making.
• Legal considerations: Nurses must consider the legal implications of their decisions,
especially regarding issues like patient consent and confidentiality.
• Example: A nurse may believe that continuing life support for a brain-dead patient is
ethically wrong, but hospital policies and legal requirements may mandate that care
continues until the family decides otherwise.
ETHICAL DECISION-MAKING MODELS
• Several models exist to guide ethical decision-making in nursing:
• The Four-Box Model (Jonsen, Siegler, & Winslade):
• Medical indications: What are the medical facts?
• Patient preferences: What does the patient want?
• Quality of life: What will the impact on the patient's quality of life be?
• Contextual features: What external factors (e.g., laws, policies) are
relevant?
CONT.
• Moral Model (Thompson et al.):
• Massage the dilemma: Define the issue clearly.
• Outline options: List potential actions.
• Resolve the dilemma: Choose the best option.
• Act: Implement the decision.
• Look back: Evaluate the outcome.
• Application:
These models provide structured approaches to resolving ethical
dilemmas, helping nurses navigate complex situations by offering step-
by-step guidance
CASE STUDY DISCUSSION
• Case Scenario:
A nurse discovers that a colleague has been making medication errors
but has not reported them. How should the nurse approach this
situation ethically?
• Questions for Students:
• What are the ethical principles involved (e.g., non-maleficence, justice)?
• Which decision-making steps should the nurse follow to address the situation?
• How would different decision-making models guide this process?
SUMMARY
• Key Takeaways:
• Ethical decision-making in nursing involves a systematic approach to
addressing moral dilemmas.
• The steps include identifying the ethical issue, gathering information,
evaluating principles, considering alternatives, making a decision,
implementing it, and evaluating the outcomes.
• Internal and external factors, such as personal values and institutional
policies, influence decision-making.
• Ethical decision-making models provide structured ways to resolve
dilemmas, ensuring that patient care is morally sound and professionally
accountable.
