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Discussion 3 – Collaborative Decision Making

Each student will identify a current or past ethical situation from your clinical practice area (Hospice).

Examine the situation based on the seven steps of the ethical discernment process.

Read each of the two papers in this week‟s list of required readings and discuss your ethical issue in relation to the steps of the process as detailed in the papers.

Please identify a specific, detailed clinical issue and not simply a general discussion of ethical situations.

â–ª Identify a current or past ethical situation from your practice

area (Hospice)

â–ª Examine the situation based on the ethical discernment

process.

â–ª Discuss your ethical issue in relation to the seven steps of

the process as detailed in the assigned papers on discernment

Ascension Health
Organizational Ethics Discernment Process
Why a process?
A STRUCTURED DISCERNMENT PROCESS:
Disciplines our decision-making
Ensures that we consider all relevant factors
Elicits multiple perspectives
Allows us to reflect on our moral intuitions and instincts
Aligns our affects, intuitions and instincts with our deliberative intellect
Why this process?
THIS DISCERNMENT PROCESS:
Explicitly relates decisions back to our Mission, Vision, Values and Identity
Reinforces our Preferred Culture
Promotes consistency with existing organizational structures, processes
and positions; e.g., Authority Matrix, Distributive Leadership Model,
Position Paper on a Positive Organizational Climate, etc.
Fosters our ability to articulate and communicate the rationale for our
decisions
Ensures major decisions are grounded in prayer and careful reflection
The Process:
DISCERNMENT ENGAGES our spirituality, intellect, imagination, intuition, and our beliefs. It
is decision-making that reaches into the heart of our beliefs about God, creation, others,
and ourselves. It therefore requires structured time for reflection and prayer from the
beginning and throughout the process. Such prayer and reflection may include but
should not be limited to the following considerations:
What would God have me do in this situation? In these circumstances?
How does this decision help us to serve others better?
How does this issue relate to our Mission?
Am I willing to step outside my preconceived plan?
Am I willing to give up control?
What are the subjective/objective facts? Events? Feelings?
How is God speaking through events, people and authority?
The following steps are intended to guide the discernment process. While the
considerations under each step are not exhaustive, they are intended to serve as a
checklist to ensure various dimensions of a decision are being considered. In group or
committee situations, each step need not be completed by every member but should be
© Ascension Health 2004
considered explicitly and discussed with all the members before a final decision is
implemented. Each step may need to be considered more than once, and earlier steps
may need to be revisited in light of responses to later steps. The entire process may be
completed in one session of deliberations, or over the course of several. Returning to
prayer and reflection between steps and throughout the process, as appropriate, is
integral to discernment.
Step One:
IDENTIFY THE CENTRAL QUESTION (S)
Clearly and succinctly articulate the issue(s).
Is the issue of sufficient significance and/or complexity that it requires a
structured process of discernment?
What organizational, ethical and strategic considerations does the issue
raise?
How does the issue potentially impact the organization in the short and
long term?
Is this an appropriate time to address this issue?
Step Two:
CONSIDER SUBSIDIARITY
Who is affected by the decision and how?
Who is most directly affected?
Who has proper authority?
Who has relevant expertise?
Is their participation in the decision-making process appropriate to the
matter under consideration?
Step Three:
IDENTIFY THE RELEVANT FACTS
Statutes & regulations
Existing institutional policies
Professional standards
Strategic priorities, needs, goals, etc.
Possible outcomes
Step Four:
IDENTIFY SALIENT VALUES AND MORAL CONCERNS
Key Principles, e.g., Human Dignity, Common Good, Justice, Fairness,
Stewardship, Human Rights, etc.
Associate rights & responsibilities
Ascension Health’s Mission, Vision, Values & Preferred Culture
Individual & Professional Values
Institutional identity, integrity & conscience
© Ascension Health 2004
Step Five:
CONSIDER ALTERNATIVES
What do other organizations do in this situation?
What do other organizations not do in this situation, but should?
What would I, as an individual, do in this situation?
What would the prudent person do in this situation?
Are there other possibilities not yet considered?
Step Six:
DECIDE & JUSTIFY
Is the decision consistent with our Catholic Identity and moral norms?
Does the decision advance our Mission, Vision & Values?
Does the decision benefit those we serve?
Does the decision reflect our Preferred Culture?
Does the decision promote our strategic priorities?
Is the decision adequately grounded in prayer and reflection?
Is there a sense of peace with the decision?
Prior to implementation, develop a plan for communicating the decision
and its rationale.
Step Seven:
FOLLOW-UP & REVIEW
Have all parties responsible for implementing the decision followed
through?
Did those responsible for implementing the decision consult and review
the implementation plan with the primary decision-makers and those who
have the relevant expertise?
Was the decision implemented in a timely manner?
Were there any unforeseen consequences?
Does the decision need to be revised in light of new information?
What can be learned from the decision and its outcome?
What should be done differently next time?
© Ascension Health 2004
ETHICAL DECISIONS
IN HEALTH CARE
A Seven-Step Ethical Discernment Process Can Help
Organizational Leaders Make Wise Choices
BY JOHN PAUL
SLOSAR,PhD
I
Dr. Slosar is director,
ethics, Ascension
Health, St. Louis.
t is sometimes said that health care ethics as
a profession is in an early stage of its maturation process.1 If this is true, it can also be
said that organizational ethics in health
care is just now beginning to emerge from
its earliest stage of development. In its infancy,
organizational ethics was generally viewed as synonymous with “corporate compliance,” in part
because a primary impetus for the development of
organizational ethics programs has been governmental pressure.2 Although governmental compliance pressure continues to be a factor, organizational ethics in Catholic health care has been evolving independently of that pressure.
By developing and integrating a view of organizational ethics that transcends its original compliance context, Catholic health ministries are transforming the role of values in organizational decision making. Integral to this transformation is a
combination of the existing emphasis on mission
in organizational decision making,’ the distinct
moral method found in the Catholic moral tradition (or, at least, in one interpretation of it), and a
corresponding conception of ethical discernment.
MORAL METHOD AND ORGANIZATIONAL ETHICS
Though not immediately obvious, a connection
exists between the way one thinks about ethics
generally and the way in which one conceives of
organizational ethics. For example, the view that
organizational ethics is synonymous with corporate compliance is consistent with the prevailing
tendencies in our acculturated moral reasoning.
In contemporary society, people tend to base
their actions either on what they think will result
in the most good or on certain rules of right
action, no matter what the outcome of the action
might be. Whereas some people recognize the
moral significance of both pragmatic results and
rules, most emphasize one of these considera38
•
JANUARY – FEBRUARY 2 0 0 4
tions more than the other. Others focus only on
consequences, or only on rules of right action,
when trying to decide what they ought to do. 4
A l t h o u g h these observations provide some
insight into everyday moral reasoning, they also
reflect the nature and character of the predominant moral methods of our day, namely, “consequentialism” .md “deontology.”
According to Samuel Scheffler, consequential ism is “in its purest and simplest form . . . a moral
doctrine which says that the right act in any given
situation is the one that will produce the best
overall outcome, as judged from an impersonal
standpoint which gives equal weight to the interests of everyone.” 5
Viewed from a consequentialist perspective,
one of the primary purposes of an organizational
ethics program is to ensure that the organization
is not penalized for the actions of its individual
employees and to avoid the bad consequences
that might result from such actions (e.g., fines,
lawsuits, etc). Indeed, this goal is the underlying
premise of “due diligence,” one of the early practical manifestations of organizational ethics in the
compliance context. However, due diligence was
originally developed not as an organizational
ethics program, but as a legal defense strategy
intended to show that the behavior of a few
rogue employees was neither encouraged nor
sanctioned by an organization’s policies and procedures.” Thus, the purpose of due diligence is to
distinguish what an organization does from what
its employees might do.
Deontologica! theories of ethics (Kantian
ethics, for example) view the moral status of an
action as dependent on its being in accord with a
duty or rule of right action. In this framework,
consideration of consequences is irrelevant/ This
conception of ethics can be summarized by the
c o m m o n phrase, “The ends never justify the
HEALTH PROGRESS
means.” From a dcontological perspective, as
from that of c o n s e quentialism, organizationaJ ethics is primarily a b o u t compliance
with existing rules and
regulations. The primary difference be
tween a consequentialist c o n c e p t i o n and a
deontological concep-
a
ates are positively
encouraged to behave
in certain ways and
e m p o w e r e d to c o n tribute to the greater
good of the organization and community.’1
• Organizational
ethics is fundamentally
concerned with fostering the well-being of
the organization itself.
its associates, those it
serves, and the larger
community in which it
exists, through means
that are themselves
morally valuable.
Although fostering institutional wud human
well-being in this way retains a necessary and
‘Value-added” role for corporate compliance and
due diligence programs, organizational ethics is
most appropriately viewed from this perspective
as a tool for making the best possible decisions on
behalf of the organization, as judged from the
standpoint of its mission, vision, md values. In
this way, a teleological conception of organizational ethics is more closely aligned with strategic
decision making than with corporate compliance.
Critical to the ability to make this conception of
organizational ethics operational is a structured
process of ethical discernment.
Tganizational
ethics is concerned
with creating a positive
tion of organizational
ethics is that, according
to the latter, there is ,m
inherent value in ensuring that associates are
treated fairly and their
rights respected. Though it is much less a “carrot
and stick” approach, organizational ethics from a
deontological perspective still fundamentally
means “compliance.”
In contrast, it can be argued that the conception of ethics that provides the methodological
basis for the Catholic moral tradition is neither
strictly conscqucntialist nor strictly deontological.
Rather than consequences or rules of right
action, the Catholic conception of ethics is primarily concerned with human dignity and human
well-being—with asking whether our actions promote and respect human dignity.8 In broad terms,
there are three basic ways in which one can promote and respect human dignity:
• By respecting the basic human rights of individuals that arise from human dignitv .\-o refraining from actions that interfere with or are contrary to human well-being
• By acting as an advocate for those who cannot speak for themselves, by being a “voice for
the voiceless”
• By actively fostering the ability of individuals
and communities to function in characteristically
human ways that enable human nourishing
One characteristic of this teleological approach
is that it requires one to act both to maximize
good consequences (i.e., those that foster human
flourishing in oneself and in others) and in
accord with rules of right action (e.g., respecting
the fundamental rights of individuals that arise
directly from human dignity).
The subsequent implications of a teleological
moral m e t h o d for organizational ethics are
twofold:
• Organizational ethics is concerned not primarily with distinguishing the actions of the organization from those of its associates through due
diligence, but, rather, with creating a positive
organizational climate or culture in which associ-
climate or culture.
HEALTH PROGRESS
ETHICAL DISCERNMENT: A STRUCTURED PROCESS
Discernment engages our spirituality, intellect,
imagination, intuition, and beliefs. It is decision
making that reaches into the heart of our beliefs
about ourselves, about those with whom we live
and work, about God, and about all creation.
Particularly in a situation in which a group of
leaders must come together to make a collective
decision, a structured process of discernment can
help discipline decision making; ensure that relevant dimensions of a decision are considered adc
quately; elicit a multiplicity of perspectives; allow
decision makers to reflect on their moral intuitions; align moral sensibilities and intuitions with
the deliberative intellect; and foster .n ability to
articulate and communicate the rationale for
organizational decisions.
Discernment, therefore, requires structured time
for reflection and prayer. Such time may includebut not be limited to considerations such as: What
would God have me do in this situation? How is
God speaking through events, other people, and
authority? How would a particular decision help us
to serve others better? How would it advance our
mission? How do my personal biases and preconJANUARY – FEBRUARY 2 0 0 4
•
39
ETHICAL
DECISIONS
IN
HEALTH
CARE
ceived plans influence my decision making?
The particular process with which I have had
some experience was developed for use at
Ascension Health, St. touts, and explicitly relates
decisions back to that organization’s mission,
vision, and values; reinforces its “preferred culture”; and promotes consistency with existing
organizational structures and processes and with
its Catholic identity. The process itself consists of
seven steps that follow an initial period of prayer
and reflection. Prayer and reflection should be
engaged, not just at the beginning, but throughout the process as is appropriate. Though how
much and at what point prayer and reflection are
appropriate will vary according to the issue’s
complexity and significance, they are in fact integral to the process. In group or committee situations, the group need not complete each of the
seven steps as a whole, but it should consider
each step explicitly before a final decision is
implemented. The group may need to consider
each step more than once, and it may need to
revisit earlier steps in light of responses to later
ones. Though the steps are represented sequentially, the process of discernment is in fact more
like a downward spiral movement through which
the decision makers drill deeper into the issue.
The steps are:
• Step One: Identify the Central Question (s)
Decision makers articulate clearly and succinctly
what they perceive to be the issue at hand; consider its organizational, ethical, and strategic
dimensions, including its potential short- and
long-term impact on the organization; and determine whether this is the appropriate time t o
address it. This step is critical insofar as those participating in the process must clearly understand
the central issue(s) before they ean adequately
consider the subsequent steps of the process.
Identifying the central issue will, for example,
help determine who should be invited to the
decision-making table.
• Step Two: Consider Subsidiarity Subsidiarity
requires that those in positions of authority recognize that all associates have a right, in accord
with their human dignity and responsibility to the
common good, to participate in decisions that
directly affect them. This step asks decision makers to consider who will be affected by a particular decision and, of t h o s e , who will be most
affected. Subsidiarity does not necessarily imply
that those with the most at stake should automatically be given sole responsibility for the decision,
only that the relevant “community of concern”
should be appropriately involved. 1 ” This step
ensures that those who are most directly affected
40
•
JANUARY – FEBRUARY 2 0 0 4
by a decision will be appropriately consulted by
those who have the ultimate accountability for
the decision and expertise to make it. It may happen that additional people will need to be
brought into the decision-making process or that
responsibility for the decision making will ultimately be delegated to a more appropriate level
(whether higher or lower) in the organization.
• Step Three: Identify the Relevant Facts Such
facts may include state and federal statutes and
regulations; case law; existing institutional policies; and professional standards. One might also
include here consideration of possible outcomes
from a particular decision. This is a particularly
pivotal step insofar as new facts regarding a specific issue may force decision makers to reconsider
whether they are asking the right questions and
whether the relevant communities of concern are
appropriately represented. This step will often
take participants back to (or be combined with)
Step One, because the situational particulars of a
given case will influence what the decision makers
can and should try to accomplish in that situation.
• Step Four: Identify the Salient Values and
Moral Concerns For Catholic organizations, such
concerns will include the foundational principles
of Catholic moral and social teaching, such as
human dignity, the common good, justice, and
stewardship, as well as other, less foundational
moral principles.
Yet such concerns go beyond moral principles
to encompass considerations that relate directly
to the organization’s well-being and culture.
These additional considerations might, for example, include the organization’s strategic priorities,
its institutional identity, integrity, MC conscience,
as well as the personal and professional values of
its associates and their rights and responsibilities.
Of course, simply identifying the salient moral
concerns and values at stake will not by itself
resolve any given issue. Decision makers must
then engage in a nonlinear process of balancing
the salient moral concerns and values, arriving
thereby at a practical judgment regarding the best
possible alternative.
• Step Five: Consider Alternatives Questions that
may help decision makers identify possible alternatives include: What do other organizations do in this
situation? What are other organizations not doing—
but maybe should be doing—in this situation: What
would I as an individual do in this situation? What
would the prudent person do In this situation? Are
there other possibilities not yet considered? These
questions are intended to elicit a multiplicity of perspectives, to generate fresh ideas, and to get the
decision makers “thinking outside the box.”
HEALTH PROGRESS
T
• Step Six: Decide
and Justify In fact, a
decision may well have
been reached by the
time the previous five
steps are c o m p l e t e d .
The value of this step is
that it torces the decision makers to articulate clearly the rationale
for their decision and
to relate it back to the
organization’s mission,
values, and Catholic
identity. This step also
highlights the essential
and integral role of
praver and reflection in
the discernment process a final time, because it
requires decision makers to ask themselves
whether the particular decision is adequately
grounded in prayer and reflection and whether
everyone is at peace with the decision. Finally,
this step requires decision makers to formulate a
communication plan for explaining the decision
and its rationale to the members of the relevant
communities of concern.
nificant strategic decision. Indeed, the process was designed to be
used in many different
types of health care
delivery organizations,
in many different types
of situations, and at the
many different levels in
such an organization.
As a result, decision
makers are left t o
d e t e r m i n e for themselves h o w best t o
work through the process. A h y p o t h e t i c a l
case example may help
illustrate how the process can facilitate the integration of values and
strategic priorities in the decision-making process.
JLhe discernment
process can be used
by a leader or team
as a checklist.
• Step Seven: Follow-Up and Review This step
actually occurs after the decision has been made
and is (or soon will be) in the process of being
implemented. It is, therefore, both retrospective
and prospective. Retrospectively, the step asks
whether all parties responsible for implementing
the decision have followed through, whether they
consulted and reviewed the implementation plan
with the primary decision makers and those with
the relevant expertise, whether the plan was
implemented in a timely manner, and whether
there were any unforeseen consequences.
Prospectively, the step asks whether the decision should be revised in light of new information, what can be learned from the decision and
its outcome, and whether anything should be
done differently the next time the organization is
faced with a similar issue. In this way. Step Seven
reinforces the importance of ethical discernment
before, during, and after the decision-making
process and fosters the ability of leaders to make
well-reasoned decisions in a consistent manner.
ETHICAL DISCERNMENT IN PRACTICE
There are many ways in which this discernment
process might be used to address an issue. It
might, for example, be used by a single decision
maker as a checklist to ensure that he or she is
considering all the relevant dimensions of a complex issue. It might be used by a leadership team
working through a particularly complex and sigHEALTH PROGRESS
In light of the recent approval by the U.S.
Food and Drug Administration of the Cypher
drug-eluting coronary stent (DES) and numerous patient requests for the stent, the chief medical officer ( C M O ) of “St. P e t e r ‘ s , ” a large
Catholic acute care facility widely known for its
cardiac services, has decided that a protocol for
determining which patients will receive the new
stent is needed. The C M O (who happens to be a
Catholic) calls a meeting with the chief operating
officer (an Episcopalian) and the chief of cardiac
services (a Muslim) to begin considering what
such a protocol might look like. Though not sure
that the development of a clinical protocol is an
appropriate issue for the discernment process, the
C M O asks each of them to prepare for the meeting by reflecting on how the use of a limited
resource influences allocation decisions and on
how this particular issue provides an opportunity
to contribute to St. Peter’s mission.
At the meeting, the C M O begins by stating
what he believes to be the central issue, namely,
that a protocol to limit DES utilization is necessary to control costs and to support physician
responses to patients who request the new DES
but tor whom it may not be clinically appropriate.
The C M O then asks the others how they think
the availability of the highly anticipated stents
might affect the organization and what other
organizational, ethical, and strategic considerations the protocol should address. During this
discussion, several other issues are identified,
including w hether patients should be allowed to
pay for the new DES out-of-pocket; what impact
the increased expenditures will have on the organization’s ability to provide “charity care” (of
which it is the largest provider in the communi-
JANUARY – FEBRUARY 2 0 0 4
•
4 1
ETHICAL
DECISIONS
IN HEALTH
CARE
ty); and how the new
technology
might
affect the already significant disparities in
health between the area
n e w
r e s i d e n t s who have
adequate insurance and
those who are underinsured.
Given these conside r a t i o n s , the t h r e e
leaders determine that
the issue would be
appropriate for the discernment
process,
insofar as it has complex o r g a n i z a t i o n a l ,
clinical, and ethical
dimensions and potentially significant operational
implications. In considering Step Two, they
decide that they should have another meeting and
invite the CEO, the vice president for mission,
and another physician staff member to ensure
that the clinical and organizational dimensions
are adequately considered. The C M O then asks
the chief of cardiac services to gather any pertinent facts. In preparation for the next meeting,
each participant is again asked to have a few
moments of private prayer.
A
XJL
identities stewardship
and patient autonomy
as particularly salient
moral concerns. T h e
CEO then notes that,
as she understands it,
the principle of stewardship requires n o t
only that resources be
used in a Way that maximizes medical utility
(i.e., that minimizes
costs and maximizes
clinical benefit) but
used also with an eye
to promoting equity,
respecting basic human
rights, and fostering
the common good.” The vice president for mission p o i n t s o u t t h a t , as interpreted from a
Catholic moral perspective, the concept of
respect for patient autonomy is not purely individual-centered and that the autonomy rights of
individuals must be understood MU responded to
in the context of membership in community, solidarity, and the goods of public life.
coronary
stent offers a hypo-
thetical case for the
discernment process.
At the beginning of the second meeting, the
vice president for mission leads the g r o u p
through a reflective exercise focused on Jesus’
parable of the talents and how its message relates
to St. Peter’s, its mission, and die particular issue
with which they are now faced. The C M O then
summarizes the issues that were identified as central in the previous meeting, and everyone agrees
that the protocol should attempt to address these
issues. The chief of cardiac services then relates
the key findings of his fact gathering, in particular
that:
• A DES costs approximately S2,000 more
than a bare metal stent.
• The demand for DES is currently greater
than the supply.
• A DES generally results in a dramatic reduction in the need for repeat percutaneous cardiac
intervention because of restenosis.
• The U.S. Centers for Medicare & Medicaid
Services have created a new DRG for the DES
that will reimburse at a higher rate, thereby covering most (but not all) of the increased cost.
• Existing utilization protocols specify the
inclusion criteria for the SIRIUS Study, which is
considered the gold standard because of its large
subject population and the way it closely approximated “real world” clinical application.”
In light of this discussion, the group quickly
42
• JANUARY – FEBRUARY 2004
After considering various alternatives for structuring the protocol, the group decides that the
protocol should, at least initially, limit DES utilization to the two subgroups of patients most
likely to benefit from them: diabetics with longer
lesions and small vessels and nondiabetics with
shorter lesions and large vessels.” The protocol
does not, moreover, allow the new stents to be
used in patients outside these two groups even if
they are able and willing to pay for the procedure
out-of-pocket.
In justifying its decision, the group emphasizes
several considerations:
• Restricting utilization in this Way will help to
reduce the temptation for physicians to overutilize the new stents.
• The protocol will provide institutional support for physicians responding to inappropriate
patient requests for the DES ,nd help ensure that
the new technology is available for those most
likely to benefit from it.
• The protocol is an example of prudent stewardship, insofar as it will constrain costs more
than would other protocols, ensure that the new
stents are distributed on the basis of need and
potential benefit rather than on the ability to pay,
and thereby prevent the widening of health disparities between the rich and poor that might
result from less restrictive allocation criteria.
Finally, all members of the group agreed that
the protocol is consistent with the organization’s
focus on the p o o r and vulnerable who arc
HEALTH PROGRESS
marginalized by society.
The group’s members then engage in a final,
collective prayer and ask if anyone has any
remaining objections or concerns. Once satisfied
that all are at peace with the decision, the chief
operating officer volunteers to work with the vice
president for communications to develop a plan
to explain the decision and its rationale to the
physicians, other medical staff, and the larger
community.
EXPERIENCE IS THE BEST GUIDE
People considering a structured process of ethical
discernment should recognize that any such process will, in its one-dimensional representation,
appear deceptively simplistic and artificially linear.
Particularly in difficult and complex cases, ethical
discernment resists being reduced to a simple for
mula. Decision makers should not, therefore, get
discouraged if they haw a difficult time following
the steps in sequential o r d e r or in g e t t i n g
through any particular step, although they should
also be careful not to get mired in one step for
too long.
Experience ai Ascension Health suggests that
the value of its structured process resides not in
its formulaic representation on paper but, rather,
in the depth .m breadth of the considerations it
guides decision makers to reflect upon.
Because ethical discernment is not a rule-based
and linear form of practical judgment, its value
cannot be gleaned from simply reflecting on the
individual steps—it must be illustrated through
experience. In other words, the best way for leaders to gain an appreciation for any discernment
process is to use one in addressing a real-life issue.
However, the issue chosen for the initial experience must be one appropriate for an involved and
sometimes time-consuming process. What constitutes an appropriate issue will vary according to a
number of factors, such as the inherent complexity and significance of the issue, the number of
people and departments affected by the decision,
the potential impact on the organization and
community, the authority structure of the organization, and the interpersonal dynamics of those
involved in the decision-making process.
Organizations may find it helpful to develop
their own set of guidelines for determining when
the use of a structured process of discernment is
appropriate. It is not necessary that someone
with formal ethics training lead the discernment
process, though consultation with an ethicist may
be helpful, particularly in Step Four. Finally, experience at Ascension Health suggests that the
greatest value of the discernment process is not
so much as a tool for identifying alternatives
(though decision makers are guided to do that),
HEALTH PROGRESS
but rather as a tool for selecting the best alternative—the alternative that, as judged from the
standpoint of promoting and defending human
dignity, best serves the organization as a whole,
its associates, the individuals it serves, and the
larger community.
D
N O T E S
1. Edmund D. Pellegrino, “Bioethics at Century’s Turn:
Can Normative Ethics Be Retrieved?” Journal of
Medicine and Philosophy, vol. 25. no. 6, December
2000. pp. 655-657.
2. E. Petry. A. Mujica, and D. Vickery. “Sources and
Consequences of Workplace Pressure.” Business
and Society Review, vol. 99. no. 1.1998. pp. 25-30.
3. As was illustrated by Paul Marceau, in “Lessons of
Moral Discernment.” Health Progress, July-August
2003. pp. 40-42, 53.
4. For a more robust discussion of the tension between
pragmatic results and idealistic principles in common moral reasoning, see John F. Kavanaugh, Who
Count as Persons? Human Identity and the Ethics of
Killing, Georgetown University Press. Washington.
DC. 2001. pp. 73-77.
5. Samuel Scheffler. Consequentialism and Its Critics,
Oxford University Press, New York City. 1988. p. 2.
See also Philip Pettit. “Consequentialism.” in Peter
Singer, ed.. A Companion to Ethics, Blackwell
Publishers, Maiden. MA. 1991. pp. 230-240, and J. J.
C. Smart and Bernard Williams, Utilitarianism: For
and Against, Cambridge University Press, Cambridge,
England, 1973, p. 4.
6. John Abbott Worthley, Organizational Ethics in the
Compliance Context. Health Administration Press,
Chicago. 1999. p. 35.
7. For a brief introduction to deontology, see C. D.
Broad, Five Types of Ethical Theory. Harcourt and
Brace, New York City. 1930, pp. 206-207.
8. On human dignity as the centerpiece of ethical decisions, see John W. Glaser. “The Community of
Concern.” Health Progress. March-April 2002. p. 1720.
9. See, for example. Daniel O’Brien and David Smith,
“Creating a Positive Work Climate,” Health Progress,
March-April 2002, pp. 46-49, 62.
10. For a detailed discussion of this concept, see Glaser,
pp. 17-18.
11. Regarding the technical dimensions of the new drugeluting stents, see J. M. Hodgson, et al., “Society for
Cardiac Angiography and interventions (SCAI)
Statement on Drug-Eluting Stents: Practice and
Health Care Implications.” Catheterization and
Cardiovascular Interventions, vol. 58, no. 3, March
2003. pp. 397-399: P. Lemos. P. Serruys. and J. E.
Sousa, “Drug-Eluting Stents: Cost versus Clinical
Benefits. Circulation, vol. 107, no. 24, June 2003. pp.
3.003-3,007: and J. E. Sousa, P. Serruys, and M.
Costa, “New Frontiers in Cardiology—Drug Eluting
Stents: Part I,” Circulation, vol. 107, no. 17, May
2003, pp. 2,274-2,279.
12. Regarding this element of stewardship, see G.
Magill. “Organizational Ethics in Catholic Health
Care: Honoring Stewardship and the Work
Environment,” Christian Bioethics, vol. 7, no. 1, April
2001. pp. 67-93.
13. See the abstract for the SIRIUS trial, available in
Circulation, vol. 106. supplement II, July 2002, p. 393.
JANUARY – FEBRUARY 2 0 0 4
•
43
A Framework
for Ethical
Discernment
reprinted from the
Health Ethics Guide
2000
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
APPENDIX I
A Framework for Ethical Discernment
1
1. This chapter is reprinted and adapted from Appendix I of the Health Ethics Guide (2nd edition) printed in 2000 by the Catholic
Health Alliance of Canada, then the Catholic Health Association of Canada. The framework is adapted from “A Framework for
Ethical Decisions in Health Care,” Dr. Michael D. Coughlin, Ethics Service, St. Joseph’s Hospital, Hamilton, Ontario, and
includes elements from “An Ethics Work-up or Work-out,” Dr. George C. Webster, Health Care Ethics Service, St. Boniface
General Hospital, Winnipeg, Manitoba.
2
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
General Guidelines
These eleven observations will aid those making ethical decisions.
1. The Catholic tradition has always respected the role of both faith and reason in ethical discernment. The teachings of the faith are not contrary to reason, nor is the use of reason a denial of the
need of faith for deeper spiritual insight and significance. The use of reason insists on using
rational understanding, the logic of consistency, clarity of terms, and transparency of information
and process.
2. There is an uncompromising recognition of both the equal dignity of all human life as a gift from
God and the social nature of human persons.
3. No human being is to be treated simply as a means to another end or to be judged on the basis
of any qualitative distinction.
4. Since the teachings of the faith are an organic whole, there is a hierarchy of truths and moral
values, all interrelated but some of more importance than others, e.g. murder is a greater moral
evil than mutilation.
5. When a conflict arises between a formally declared teaching of the church (e.g. innocent human
life must be protected) and a possibly compromising procedure, preference must be given to
human life unless another human life is equally being threatened, in which case the principle of
double effect may be used.
6. When situations arise involving morally controversial treatments or procedures which are supported by reputable ethical opinions and not specifically prohibited by church teachings, such
views may be legitimately followed, e.g. some treatments for ectopic pregnancies, the withholding/withdrawing of nutrition or hydration in some situations.
7. Christian ethical discernment also attends to the moral promptings of God as we experience
them internally, e.g. intuition, emotions, imagination and “gut-feelings.” These promptings have a
legitimate place in ascertaining moral correctness.
8. Feelings of interior harmony and integration can be valid indicators of God’s Spirit when informed by objective criteria including medical information, legal obligations, church teaching,
Sacred Scripture, and the authority of experts.
9. Sound ethical discernment is usually best made through a team approach which involves the
person receiving care, health care and social service professionals and a bioethics consultation.
10. The discernment process can be facilitated best in a prayerful atmosphere where reasoned
presentations and adequate time are provided.
11. Every effort should be made to resolve ethical conflicts by using communication and dialogue,
remembering that God does not expect the impossible in our efforts to respect the dignity of life.
3
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
DISCERNMENT PROCESS
The following model is a framework that identifies the key elements of a discernment process. It offers a way of
focussing attention on the questions that should be raised in addressing ethical decisions in health care. It provides
a process for integrating into such decisions the values and principles articulated in the Guide.
Begin with prayer and quiet reflection
A. OBSERVE
1. Identify the Problem
Name the problem clearly. Where is the conflict?
What seems to create difficulty?
Is the conflict between individuals?
2. Acknowledge Feelings
What are the “gut” reactions? biases?, loyalties?
What are the initial feelings about the case?
4
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
3. Gather the Facts
Issues to consider:
a. Clinical factors: (diagnosis, prognosis, certainty?)
b. Psycho-social factors: (history, family situation?)
What are the ethically relevant facts?
Whose account of the “facts” counts?
Have all relevant perspectives been obtained?
B. DELIBERATE
4. Consider Alternatives
Issues to consider:
a. What are the alternative courses of action? All options should be seriously considered
before eliminating any.
b. What are the likely consequences? e.g. medical, quality of life, relationships, legal,
moral/spiritual
What are the alternatives? Probable consequences?
Alternative 1.
Alternative 2.
Alternative 3.
5
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
5. Examine Values
Issues to consider:
a. Preferences of the person receiving care: wishes, values, beliefs?
b. Are others’ values relevant?
c. What beliefs/values of the Christian community are relevant?
d. Which of the values are in conflict? What is the problem? Whose values conflict?
Economics involved?
What are the important values?
Whose?
What is the good we seek?
6. Evaluate Alternatives
Issues to consider:
a.
Identify the decision-maker(s). Who speaks for the person receiving care?
b.
Rank values.
– Dignity of the person;
– Respect for life;
– Interconnectedness of every human being;
– Common good;
– Solidarity;
– Stewardship.
c. Justify ranking. By what principles?
– Totality;
– Double effect;
– Benefits/burdens;
– Legitimate cooperation;
– Subsidiarity;
– Informed choice;
– Confidentiality.
d. Evaluate the consequences of alternatives in terms of principles.
e. What alternatives are excluded?
6
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
Who is the appropriate decision maker(s)?
Rank Values
C. ACT
7. Articulate the Decision
Issues to consider:
a. Which alternative best reflects the ranking of values?
b. Which alternative best balances more of the values?
c. Have any other alternatives come to light?
State the decision.
7
Appendix I: A Framework for Ethical Discernment
reprinted from the 2000 Health Ethics Guide
8. Implement the Plan
Issues to consider:
a. How best to communicate the decision?
b. Who needs to know it?
c. How best to document the process?
d. Who needs to act?
How should the decision be carried out?
Concluding Review:
What are the feelings of those involved?
Conclude with a prayer or reflection
Conclusion: In working through the discernment process, practitioners may gain insight into the
decision to be made. The experience may also help them identify opportunities on a wider institu
tional level for policy change, education and research. Some cases will result in the identification of
opportunities for education or collaboration with community agencies, other organizations and
persons needing care.
8

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